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The history of orthoses and their use is long and hono rable.

No doubt, the first application occurred in the fi eld of fracture splinting. Skeletons of the earliest kno wn humans show evidence of fractures that healed in r elatively good alignment. One example of such early evidence is an origi- na l Neanderthal skeleton that has an ulna with a well -aligned healed fracture. Until recently it was not unreasonable to suppose that splinting of some typ e had been performed, but perhaps this was evi- d ence only of an isolated ulnar fracture. In the excavation of the Nubian Desert, the first di rect evidence of fracture bracing was found. There mummies of the fifth dynasty (2750 to 2625 B.C.) still had splints intact and wrapped within the buri al clothes. These splints appeared to have been ad equate and relatively effective by current standard s. Closed reduction and splinting were described in g reat detail by Hippocrates prior to his death in 370 B.C. He stressed that for complete immobilization of the femur, the splint had to include the hip and knee. In addition, he specified that the pressure po ints of the splints should not be over bony protube rances. Galen (131-201 A.D.) may have been the first to u se dynamic bracing for scoliosis and kyphosis. In addition to his devices, he employed breathing exe rcises, loud singing, and voluntary expansion of th e concavity to treat these conditions. He also used a type of chest jacket to control the direction of ch est expansion. This would seem to be the prototyp e of the Correl casts, which utilize chest expansio n in the treatment of scoliosis. The splints and braces of the next 1000 years were probably heavy, clumsy, and of marginal efficienc y. The standards of European medicine in general were well below those of the Greeks and early Ro mans, and there is little reason to assume that the orthoses used were any different. In the twelfth ce ntury the medical school at Bologna became a wor ld leader, and the application of braces was consid ered an important part of medical knowledge. Adv ances made by the medical school consisted of sta ndardizing, simplifying, and lightening the existin g models. Applicances of wood and metal were us ed for the back and extremities. Ambroise Pare (1510-1590), the predominant surg eon of the sixteenth century, devoted an entire boo k to orthoses, prostheses, and other assistive devic es. In it he described spinal corsets, fracture brace s, and weight-relieving appliances for hip disease. He also described special shoe modifications for c lubfoot. From the seventeenth century on, alteration of pre existing devices was associated with nearly every famous surgeon and many famous physicians. Gel sson (1597-1677), professor at Cambridge, wrote about rickets and used orthoses to straighten the b owleg deformities. Venel of Geneva established th e first hospital for musculoskeletal disease in 179 0, and in his writings scoliosis and clubfoot braces received particular emphasis. About the same time Levacher and Portal, independently, developed spi nal defices with head suspension systems, the fore runner of the present halo casts and braces.

mid-1700s. He was unconcerned with fractures but devoted his energies instead to the preventio n of de- For deformities of all types, he used ort hoses. His dictum: "If the spine be crooked in th e form of an S, the best method you can take to mend it is to have recourse to the whale bone bo dice, stuffed parts shall exactly answer to those protuberances which ought to be repressed, and t hese bodices must be renewed every three mont hs, at least." What a job for the orthotist in a bus y clinic! Andry also used dynamic devices for lordosis.
You must give the child a pair of stitched stays contrived in such a manner that if the belly advances forward they may push it bac k, and if the back side sticks out too much they may push it inwar ds. There are a few stay makers but can easily contrive them so a s to answer these purposes.

No brief history of bracing would be complete w ithout special mention of Nicholas Andry, Profe ssor of Medicine at the University of Paris in the

Would that we could be so optimistic about the valu e of most of the present orthoses to control lordosis! In the nineteenth century the relationship betwe en bonesetters and bracemakers became increasi ngly close, and a personal bracemaker was a part of every "orthopaedic office." This closeness led to use of the term mechanosurgery to describe or thopaedists. Hugh Owen Thomas, who is best k nown for his fracture splint, exemplified this rela tionship. He and his orthotist designed orthoses t o control almost every joint. His long hip splint i s not unlike the ischial weightbearing orthoses o f today. After World War II, advances in prosthetics wer e remarkable. New fitting techniques, new mater ials, and new concepts of design all aided the am putee. There was no similar technologic progres s in orthotics, however. As recently as the early 1970s it seemed appropriate to describe the field of orthotics as the most personal, parochial, and provincial portion of orthopaedics and rehabilita tion. Of the hundreds of devices that were availa ble for most conditions only a few were used in any one community. These were known by local names, and two orthoses with striking resemblan ce might be differently named. The rationale for the selection was poorly understood by the presc ribers. Consequently, residents and students wer e totally unaware of any reasoning behind the ch oice. Their role, then, was to learn by rote which orthosis to prescribe so as not to offend their eld ers. If they moved to a new region of the countr y, the entire learning process had to be repeated. The significant advance in orthotic thinking cam e as a result of the close cooperation between me dicine and engineering. From this developed the idea that the attention of both the physician and t he orthotist should be focused on the biomechan ical deficits of the patient, not the specific diseas e process. This application of biomechanics to th e handicapped person gave the orthopaedic surg eon a rational and generic basis for the prescripti on of an orthosis best suited to a particular patie nt's need. As a means of emphasizing this conce

pt, the biomechanical analysis system was devel oped. Although such a form is intuitively used b y the knowledgeable practitioner, the explicit for m provides a model that is helpful to the young physician in developing the concepts of biomech anics and patient needs. All orthoses are force systems that act on the bo dy segments. This is true whether the orthosis is used for support, correction of a deformity, or st abilization of a joint or limb, and the implication is that the forces which an orthosis may generate are limited by the tolerance of the skin and subc utaneous tissue. In many applications of orthoses this is not a pro blemparticularly when devices are designed to st abilize a joint in one plane while allowing motio n in another. In other conditions the corrective f orce applied by an orthosis may be of such magn itude as to place the skin at risk. This is particula rly true when compression forces alternate with sheer forces. Forces of large magnitude are gene rated when an orthosis is used to overcome sever ely spastic muscles or the ground reaction force i n a large heavy person. This leads to the realization that there are times when an orthosis cannot fulfill the expectations placed on it. If a large disparity exists between t he expectations and the actual result, the orthosis is usually blamed rather than the recognition ma de that the indications were exceeded. This tend ency to fail to recognize the limitations and then decry the results infests the entire orthotic field, from cerebral vascular accidents to scoliosis, fro m fractures to deformities in children. The authors in the present volume do not agree with those who propose that orthoses are the defi nitive treatment for most conditions. Rather they have carefully attempted to delineate the particul ar conditions for which orthoses are appropriate, those for which surgery is more appropriate, and the interaction betweeen the two. A few words about words. The names of correc tive devices and their makers have been in a stat e of flux since the time of Nicholas Andry. His c orrective devices were called "stays" and the peo ple who made them "stay makers." In the ninete enth century, particularly in England, the correct ive devices were called "irons," as a brief survey of their appearance will demonstrate was approp riate. The makers of these then were called "iron mongers." In the United States in the twentieth c entury, corrective appliances came to be calle d "braces" and "brace makers" people who prod uced them. In today's terminology orthosis is fre quently chosen to refer to an apparatus that provi des support or improves function of the movable parts of the body. These are designed -and produ ced by orthotists. As with other words, however, this one has also led to some confusion. In the current volume, produced by the America n Academy of Orthopaedic Surgeons Committee

on Prosthetics and Orthotics, the word ORTHOTICS is a noun referring to the field of knowledge abo ut such devices and their use. The device itself (also a noun) is an ORTHOSIS. A room full of these devices would contain many "orthoses." If we ar e thinking or speaking about a device, the word ORTHOTIC is the adjective of the family. This cust om does not seem to be honored by an increasin g number of publications, however, for the adjec tive often is used as a noun. It is hoped that this Atlas will set the example in correct usage of the se words, despite the slipups that may occasional ly get by. SELECTED READINGS
Andry, N.: Orthopaedia. Book II (translation), London, 17 43. Bick, E.M. Source book of orthopaedics, New York, 196 8, Hafner Publishing Co., Inc. Garrison, F.H.: History of medicine, Philadelphia, 1929, W.B. Saunders Co. Rang, M.: Anthology of orthopaedics, Baltimore, 1968, T he Williams & Wilkins Co.

Eugene F. Murphy Albert H. Burstein Availability and choice of materials The increasing availability of a wide variety of materials for orthotic appliances-some with cent uries of use, others with a background of decade s, and a growing number from the space age-imp oses greater responsibility for wise selection. In addition, new materials open possibilities for no vel designs and offer opportunities for solutions to perennial problems such as breakage, bulkine ss, clothing damage, poor hygiene, or inadequate support. Selection of the correct material in the right plac e for each appliance depends on understanding t he elementary principles of mechanics of materi als, concepts of forces, deformations and failure of structures under load, improvements in mecha nical properties by heat treatments or other mean s, and design of structures. The choice, today, a mong materials is already extensive. Metals traditionally were used for structures and are still needed in some applications, although th eir share of the total market has decreased in rec ent years. Useful metals include several types of steels, numerous alloys of aluminum, and (to a li mited extent) titanium and its alloys. Plastics, fa brics, rubbers, and leathers have wide indication s; and composite structures (of epoxy or plastic matrix plus reinforcing metal "whiskers" or boro n or graphite fibers) are being studied. In the fiel

d of plastics the laminates of knitted or woven fa brics (often themselves synthetics) with thermos etting plastics like polyesters and epoxies are in competition with thermoplastics such as polyeth ylene, polypropylene, polycarbonate, ionomer, a nd acrylonitrile-butadiene-styrene (ABS). Despite publicity for exotic new materials, and a ccelerating research, there is no single magic ma terial that will serve as a panacea for all orthotic problems. One reason is that different and even diametrically opposite properties are needed for special clinical situations or even parts of the sa me device. Elastic properties are an example. Sti ffness of the structure may be desirable for a kne e-ankle-foot orthosis (KAFO) intended to suppo rt body weight. By contrast, considerable flexibil ity and range of motion are necessary if an ankle orthosis is to allow plantar flexion in response to heel strike. Static strength and resistance to deformation are needed by heavy patients. At the same time duct ility is essential during the process of fitting a m etal bar to the contours of the individual person. These rigid members are permanently deformed by the very high local stresses that the orthotist d eliberately applies with the bending irons. Becau se of the need for a permanent set, the orthotist d islikes excessive elasticity, which would require overbending to allow for springback; and it is ce rtainly hoped that the patient's weight will not ca use further plastic deformation or breakage. So that widely divergent mechanical demands ca n be met, combinations of material are commonl y used to construct an orthosis. The cuffs of conventio nal metal orthoses generally are made of steel or alu minum. These are then fitted with felt pads and leat her covers held in place with rivets of copper or a so fter grade of cuff metal. Springs, dampers, or locks often involve combinatio ns of materials. A spring, typically formed from a st rip of high-strength wire, is often inserted in a struct ure of another material. In recent years flexible plast ics, such as polypropylene, capable of indefinitely la rge numbers of repeated bends, have been used as hi nges with or without significant spring-return effect. Sometimes these hinges are attached to plastic lami nates or other structures, such as body jackets. In so me cases they serve as an integral joint (e.g., an ankl e joint) in an orthotic structure that is stiffened in ot her portions by inherent shape or the deliberate addi tion of corrugations. 19 Another example of combinations of materials occu rs in many efforts to protect against corrosion. A ste el frame, if not made of stainless steel, may be coate d with plastisol and heated or cured. or it may be pla ted with a combination of materials, such as copper first, then nickel. and perhaps chromium. Aluminum orthoses may be given an electrochemical anodizing treatment to form a tough relatively .hick film of alu

minum oxide on the surface, a special case of the co mbining of materials. Color added in the anodizing bath may be used to simulate costume jewelry, just as eyeglass frames are sometimes designed as "fashi on eyewear" instead of camouflaged. Composite materials are still not widely used despit e the fact that availability is improving, working tec hniques are better understood, and costs are decreasi ng as uses are found for these materials. Most comp osites were developed for extremely demanding app lications in aerospace or in high-performance aircraf t. Graphite fibers laminated with epoxy or acrylic ha ve extreme stiffness, although brittle failure with lo w energy absorption is a severe imitation They are l ess expensive than boron composites. They may be combined with thermoplastics, often transparent, tra nslucent, or flesh colored, that are heated until softe ned and then draped, stretched, and usually vacuumformed 56,62,64 over plaster models. The orthotist can now purchase prefabricated. persh aped, but moldable composites of glass and carbon f abrics in acrylic thermoplastic resin that can be inco rporated in the molding of thermoplastic orthoses. F or example, crescent-shaped portions with chamfere d edges can be heated, molded, and adhered behind and below the malleoli on a plaster model and firml y trapped during vacuum forming to stiffen and rein force a foot-ankle orthosis designed to prevent ankle motion. 21 The unit cost of material used in orthotic devices is a relatively insignificant part of the total investment. A far greater sum has been spent in assuring the ade quacy of fabrication and assembly and the professio nal services of fitting and aligning to the individual. Hence even large variations in unit prices of compet itive materials are not of great importance. More important than unit price of materials are facto rs like physical properties, stability during use over a substantial range of temperatures, endurance unde r repeated loading, resistance to wear and corrosion, and ease of working in the shop and adjusting in the fitting room. The economic choice among suitable materials may also depend on the number of steps a nd time required for initial processing, adjustments, and maintenance. When compared with the additional steps and delay s in delivery that can occur in the plating of ordinar y steels, the direct use of expensive stainless steel is often economically justified. Similarly, the speed an d simplicity of molding thermoplastic synthetic bala ta directly on the body without discomfort is very at tractive, particularly for temporary orthoses, when c ompared with the additional cost and delays involve d in preparing a plaster cast and then a plaster mode l before using other thermosetting plastic laminate. Nevertheless, vacuum forming of a hot sheet of ther moplastic material against a plaster model appears t

o have advantages. To test materials and to specify reproducible recipes once proved successful in clinical application, we n eed detailed standards and specifications for raw ma terials, treatments, and methods of construction. For tunately, many exist already and more are being dev eloped by professional societies, trade associations, and commercial companies. Both individual laborat ories and the postgraduate prosthetics-orthotics educ ation schools are writing manuals detailing step by s tep which construction methods have proved most s uccessful*, and federal, state, and local government s have a variety of procurement specifications. The American Society for Test
*References 3. 19. 20. 29. 36-38. 43-47. 39. 63.

When a force is applied to an object, either some type of motion is created or, when this cannot oc cur. the energy is absorbed within the structure t o cause a change in shape. This static situation is significant to decisions relating to orthotic desig n. Stress and strain are the terms employed to de fine the acting forces and their effects.

ing and Materials, in its multivolume Annual Book of ASTM Standards,2 includes a number of specifica tions, test methods, and recommended practices app licable to orthotics and to surgical implants. Reasons for engineering mechanics and solid me chanics For a number of reasons, a general (even if intuit ive) understanding of engineering mechanics, so lid mechanics, and strength of materials is impor tant to the members of the orthotics clinic team a nd especially to the orthotist. A general understa nding of stresses, strains, and total deflections ar ising from loading of structures, particularly fro m the bending of beams, is needed. The physicia n and the orthotist can then appreciate the import ance of simple methods to allow controlled defo rmation during fitting, to provide stiffness or resi liency as prescribed, and to reduce breakage whe ther from impact or from repeated loading. Certain problems can be solved by a branch of st udy called engineering mechanics, usually subdi vided into statics (analysis of constant forces on an orthosis when it is stationary) and dynamics (analysis of moving or changing forces). From k nowledge of external gross forces on a structure, whether animate or inanimate, it is often possibl e to calculate the major internal forces at joints or within beams, bones, etc. The basic concepts of solid mechanics applicable to orthotics will b e presented in a relatively nonmathematical fashi on. Much also can be learned from kinematics, "the mathematics of motion," the science that describ es motion without immediate regard to the force s involved. The complex motions of the human knee, for example, have been described by use o f kinematic techniques. This chapter does not attempt to cover the engin eering mechanics of structure or the kinematics of the body or the experimental and analytical m ethods of analysis. Some sources, however, are s uggested in the reading list.7,22,23,28,48,58

Strain. The term strain refers to the change in sh ape within a material whether it is visible or mic roscopic. There are two basic types of changelen gth and angular. Length change, or normal strain. When an ext ernal load is applied to the ends of a bar, a chang e in length occurs. This type of deformation is ca lled normal strain, because the force is perpendic ular (or normal) to the cross section studied. Nor mal strain is designated by the Greek letter epsil on (e). It is the change in length as a proportion of the original length. With change being design ated by the Greek letter delta (), this relationshi p is expressed as L/L (Fig. 2-1). Normal strain is therefore a practically dimensio nless quantity. Since most of the normal strains with which we deal in using metals are very sma ll (on the order of several millionths or 10-6), we often talk in terms of microstrain. One microstra in represents a change in length of one part in on e million (e.g., 0.000,001 cm/cm or inch/inch). Two types of normal strain can occur-lengthenin g and shortening. When the length of the structu re increases, it is called a tensile strain and recor ded as a positive number. Shortening is a compr essive strain and is expressed as a negative num ber. Normal strain is easily measured by a variety of techniques. One common strain-measuring devic e is a strain gauge, which translates the length ch ange into an electrical signal. Constructed of a s mall coil of wire (Fig. 2-2), it is glued onto the s urface of the object to be measured. The electric al resistance of the wire alters as the material to which it is fastened receives strain. The change i n electrical resistance is proportional to the norm al strain. Such instrumentation is capable of mea suring strains as small as one one-hundredth of a microstrain. The distribution of strains on the surface of an o bject can be described by applying a brittle coati ng and then studying the pattern of cracks that re sult from loading. Mechanical devices that magn ify small motions and display the results opticall y are also used. Angular change, or shear strain. When the ext ernal load is applied obliquely in the cross sectio n studied, the change in the object is an angular deformity. This is called a shear strain. It can be readily demonstrated by drawing two lines on th e object's surface at right angles to each other an d

nothing their change (Fig. 2-3). After the material o n which the lines are scribed is subjected to an exter ~al load, the lines will no longer be perpendicular b ut will be deformed by the angle gamma (). Aeme shear is an angular deformity from the origina1 nor mal (perpendicular) state. Shear strain is defined as t he tangent of . For most materials the magnitude of shear is sufficiently small to allow the approximatio n tan where is measured in radians. (A complete circle [360 degrees] equals 2p radians; so 1 radian is appo ximately 57.3 degrees, and 90 degrees equals 2p ra dians. ) Cambimed normal and shear strain. The exisc of st rain in a material is not a simple onedemensional co ndition. Tension and compression strains are always associated with shear strains. this can he demonstrat ed by drawing a square and its diagonals on the obje cts's surface (Fig. 2-4). Application of equal and op posite forces compressing the faces parallel to lines b and d would cause shortening (compressive strain) of lines a and c but a smaller lengthening (tensile str ain) of b and d. For convenience, we can apply diag onal forces just sufficient to cause shortening of the horizontal top and bottom but to create no net chang e or strain in the vertical lines. At the same time the diagonals, which initially intersected at right angles, assume a different angle. They have suffered shear s train. A similar pattern of deformity occurs with ten sile strain of the horizontal lines (Fig. 2-5). We have chosen to examine only a limited number of lines of the infinite number that could be drawn on the squar e. It is easily demonstrated that only lines b and d re main strain free. All others undergo either tension or compression whereas any line pair not parallel to th e edges suffers shear strain as well. The reciprocal behavior occurs if the sample of material is deformed by an oblique load (Fig. 26). In this case the square deforms into a parallel ogram. Line pairs a-b, b-c, c-d, and d-a undergo shear strain but not normal strain. The diagonal l ines, e and f, however, do undergo tension and c ompressive strains respectively but do not suffer shear strain; they remain perpendicular to each o ther. This inherent interaction between induced strain s is vital to an understanding of material behavio r. The general principles are valid for all solid m aterials.28 Stress. When an object is stationary, it is said to he in equilibrium. This is the case when the net f orce acting on the object is zero. At the same tim e each portion of the structure also is in equilibri um and all the forces acting on any portion shoul d sum to zero. In response to externally applied l oads, new internal (intermolecular) forces are ge nerated. These may he imagined as "glue" holdin g the structure together. They may also be consi dered as existing at every point on any cross sect

ion. Their distribution over the particular areas o f concern is described as stress. Stress is generally defined as the load per unit cr oss-sectional area of a material. Because the con cern usually relates to internal changes, it may al so be defined as the ratio of the force applied on an internal surface to the area of this surface (Fi g. 2-7). For analysis we can imagine that the orig inal body is divided at a designated plane; the int ernal forces on this area are now "external." This area represents an internal surface with a unifor m distribution gion. of forces acting on it exactly equal to and opposite the forces on t he formerly contiguous wall of the other portion, which has been removed. When the internal force distribution is not of uni form intensity, the determination of the magnitu de of the stress on any portion of the surface req uires that the total area be subdivided into suffici ently small portions to allow the force to be cons idered uniformly distributed over each small regi on. Normal stress. When the forces are perpendicula r to the surface on which they act, the ratio of for ce to area is called normal stress. This is designa ted by the Greek letter sigma (s). If the force acting on a particular area is directed outward from the surface, it is said to be tensile s tress (Fig. 2-8). Conversely, when the force is di rected perpendicularly into the surface in questio n compressive stress exists (Fig. 2-9). The distri bution of normal stress acting on a plane may in clude both tensile and compressive stresses. 28,58 Shear stress. When, instead of acting perpendicio t he internal surface, a distributed force is parallel to t he surface, the ratio of the force to the surface on w hich it is acting is called shear stress (Fig. 2-10) Combined normal and shear stress. It is import ant that shear stress and normal tensile or compr essive stress may exist simultaneously on any int ernal surface. Actually coexistence is the far mor e usual situation. An example would be the anal ysis of a section from the bar of an orthosis subj ected to a compressive load (Fig. 2-11). It is reas onable to expect that the small element selected for analysis will also be subjected to compressiv e forces on its transverse planes (planes a and b). The combined stress can be demonstrated by slic ing the cube on a diagonal and examining the lo wer portion (Fig. 2-11). A force (F) is required on a diagonal plane (c) to keep the small element from moving upward in r esponse to the force on the lower face. It is the st resses acting on surface c that produce this net d ownward force, thus maintaining equilibrium. S uch a force (F) can be considered to have two co mponents, F. perpendicular (normal) to plane c a nd F, parallel. Each of these components of force

F is related to a stress on surface c. The con dition of stress on surface c thus consists of com
pression stress attributable to F. and shear stress attributable to F, In an analogous manner, if the s

trut were subjected to a pulling or tensile load, th e diagonal plane would have tension and shear st resses imposed on it. In general, when a member has normal stresses on transverse planes, all othe r internal planes except longitudinal planes have stresses on them. Each plane has normal and she ar stresses in a proportion dependent on its angle relative to the longitudinal axis. On planes locate d at 45 degrees there is a tension (compression) s tress equal to half the tension (compression) stre ss on the transverse planes. Twisting or loading a structure in torsion induce s shear stress. Fig. 2-12 shows a small piece of material in a tubular strut that is being twisted. T he shear stress created on each longitudinal (a) a nd transverse (b) face is the same as the other she ar stresses. The small cube is in equilibrium. sin ce the forces and moments produced by the shea r stresses sum to zero. If we examine half the cu be after slicing along one 45-degree diagonal (Fi g. 212), we see that with forces produced by the shear stresses on only two surfaces (a and b) the piece of material would not be in equilibrium. W hat is needed for equilibrium is a force acting on surface d. This required force (D) is perpendicul ar to surface d and therefore produces a tension s tress. A similar argument would show that the ot her 45 degree diagonal plane (e) would be subje ct to a compressive stress (E) (Fig. 2-12). In gen eral. then. if a material is directly subjected to sh ear stress (e.g., that caused by torsional loading). there are shear stresses of equal intensity on the t ransverse and longitudinal planes. On the 45-deg ree diagonal planes there are only tension or co mpression stresses. The magnitude of these stres ses on the 45 degree planes is equal to the magnitude of the shear stresses on the transverse and longitudinal planes. H owever, on diagonal planes not at 45 degrees to the axis there are both normal (tension or compression) and shear stresses. Note that the concept of stress involves a force d istributed over an internal surface in a material. Because this internal force distribution is inacces sible, it is not possible to measure stresses direct ly in solids. We can only calculate stresses by kn owing the shape of the structure, the nature of th e loading, and the properties of the material. Experimental relationship between stress and s train. Many times it is desirable to know the ulti mate loading condition that a material can tolerat e in terms of stress. For instance, some forms of aluminum are classed as capable of resisting 414 meganewtons per square meter (MN/m2) of tens ion or 60,000 psi (lb/in2) before deforming perm anently. Although stress is not directly measurab le, the levels of stress in a complex shape can be determined by measuring the strain exhibited in response to controlled loading and applying kno wn stress-strain relationships. To determine the relationship between stress and strain for a particular material, several standard t

ests have been established. The most common of these is the tension test. This procedure requires the gradual elongation of a carefully prepared sa mple of material along with simultaneous measu rement of the induced load and the elongation of a section of uniform cross-sectional area. The no rmal tensile stress can be calculated by dividing the load by this area. The specimen is designed t o provide uniform stress distribution across the a rea of the gauge section. The strain is calculated as the ratio of the change in length of the gauge s ection to its original length. Stress is then plotted against strain (Fig. 2-13). In this schematic diagr am, for clarity the strain during the initial straigh t~line elastic portion is exaggerated compared to the remaining plastic strain to breakage at x. stress-strain curve for a mild steel depicts the mo st important parameters of the usual structural materials: elastic range, yield point, plastic range, a nd fracture point. The initial portion of the curve is virtually linear. If the material is loaded up to point a within this linear region and then unloaded, both s tress and strain will return to 0. This type of behavio r is termed elastic and the linear portion of the curve (0-b) is called the elastic region. Springs, for instanc e, are designed to operate within this region elastic deformation is reversible on removal of the stress. T he slope of this region is known as the modulus of e lasticity, elastic modulus, or Young's modulus (E) a nd is a measure of the stiffness of the material. If the stress is increased significantly beyond the linear region, say, to point c, then permanent stra in is produced. If the induced load is allowed to return to 0, the decreasing curve will be parallel to the elastic region but will intersect the horiz ontal axis (with a residual strain e). There will re main a plastic deformation equal to 0-e. This con cept is used in forming orthotic components wit h bending irons. Although the "snapback" strain that occurs elastically is reversible, that which o ccurs plastically is permanent. To distinguish more clearly between these two b ehavioral regions, one must define a measurable point (d in Fig. 2-13). A sample loaded to this va lue and then unloaded will retain a deformation of 0.2%. The stress at d is called the yield stress. The highest point on the stress-strain curve (0 re presents maximum nominal stress calculated fro m the original cross-sectional area of the test spe cimen. The stress at this condition is called the u ltimate stress. Further loading at this point cause s the material to reduce its cross-sectional area at some point. This necking is caused by shear strai n on the 45-degree planes and can be easily seen in a steel or aluminurn tensile specimen. The amount of permanent or plastic deformation that a material will undergo before failure is call ed its ductility. To varying degrees, most steels a nd surgical metals are ductile materials. Materials that do not plastically deform before fr acture are called brittle materials. Glass at ordina

ry temperatures is a brittle material. The stress-st rain curve for it shows no flattening to the right of the elastic curve (Fig. 2-14), that is, no plastic deformation before fracture. The strain is compl etely reversible in this material for any loading c ycle before failure. By contrast, at elevated temp eratures the glass softens, allowing large perman ent strains at very low stresses. For many materials, on release of the load, the c urve does not retrace itself as the specimen regai ns its original shape. The closed loop formed by the loading and unloading cycle is called the hys teresis curve. It is a measure of the amount of en ergy the material absorbs each loading cycle. Brittle materials, though sometimes attractive be cause of their high ultimate strength, may be uns uitable for shock loading under impact because t hey cannot absorb much energy before fracturin g. For example, a hard brittle steel with an ultim ate stress of 975 MN/m2 (141,000 psi) and a 5% ultimate strain (Fig. 2-15) can absorb, before bre aking, only about one third the energy of a mild steel 'th a yield stress of 325 MN/m 2 (47,000 ps i), an ultimate tensile strength of 490 MN/m 2 (7 1,000 psi), and about 25% ultimate strain at brea kage. One may best visualize this behavior by o bserving the area under the stress-strain curve, a direct measure of the energy required for failure. This comparison, however, is based on the total energy required for failure, not the amount of en ergy required to deform the material permanentl y. In certain cases permanent deformation is tant amount to failure. For an elastic material the am ount of energy required to deform it permanentl y is dependent on the yield stress and the elastic modulus. Actually, the energy required to defor m a volume of metal permanently is given by th e equation

where is the yield stress and E the elastic modulus. The higher the yield stress for a given modulus (Fig. 2-16, A) or the lower the elastic modulus for a given yield stress (Fig. 2-16, B), the greater will be the en ergy required before plastic deformation occurs. Un der shock loading, then, a material of high yield stre ss but relatively low modulus -a "resilient" materialmay be desirable. Failure of materials. There are two general type s of elastic materials, brittle and ductile. These te rms actually describe failure modes under custo mary loading conditions. Unusual conditions suc h as sharp notches, extreme stiffening, or other u nusual configurations may so alter the customary behavior of many ductile materials as to cause br ittle fracture. For most applications, though, the ductility of a material (expressed as percent elon gation to failure) will indicate the mechanism of probable failure under a single overload. Most e ngineering metals have a ductility falling betwee n 10% and 40%. The general tendency within a f

amily of materials is for decreasing yield strengt h to correspond to increasing ductility. Thus stru ctural steel has lower yield stress but much great er ductility than does the hardened toof steel in a chisel; a softer aluminum alloy, such as 2024, lik ewise has lower yield stress but higher ductility t han does hardened tool 7075-T6 aluminum alloy. A ductile failure is indicative of simple onecycle overload generally arising from an emergency. I n an orthotic device, permanent deformation-or e ven rupture after extensive distortion-may indica te desirable energy absorption, protecting the pat ient during an accidental fall. Such failures are id entified by distortion of the structure in the regio n of the fracture. The pieces when reassembled d o not reproduce the shape of the original structur e. The fracture area will usually be reduced in cr oss section. Such failures suggest a need to reeva luate the design because of functional overload e ven if this is under emergency conditions. Decisi ons must be made as to the probability of future similar loads as well as the safest course of event s. There is little value in protecting an external o rthotic device against failure but ensuring that th e patient will fracture a bone! Fractures of brittle orthotic materials can be caus ed by discontinuities in structural members. In a structure under load, any notch or geometric disc ontinuity is most serious because it tends to incre ase the local risk of failure above that which wou ld otherwise be present. The sharp bottom of the notch so concentrates the forces that load per uni t area (stress) can be doubled or trebled. This ma y initiate a crack, which raises the stress even fur ther and creates a self-propagating situation until the entire structure is fatally weakened and fails under an ordinary load. Obviously, the goal must be to avoid the "sharp-blade" effect of a narrow crack and to blunt the "cutting edge" of any notc h or reentrant corner by making it as shallow and rounded as feasible. 42 In this direction, paradoxi cally, a part may be strengthened greatly by havi ng a hole drilled to blunt the leading edge of a cr ack or by removing material on either side of a Vshaped notch to create a smoother broader Ush aped trough. Similarly paradoxically, a stronger, stiffer, but more brittle material may embody gre ater risk of breakage during clinical use with rep eated loads and occasional impacts and accident al scratches than a seemingly lower-strength but more flexible, tougher, and more ductile material (which absorbs blows and stretches slightly with out breakage to blunt the leading edge of a crac k). Fatigue fracture. Multiple loadings, producing s tresses of insufficient intensity to cause yielding, may cause a structure to fail by a process known as metal fatigue. This rather complex process ent ails the initiation and slow propagation of cracks through the material. The cracks, which usually s tart at the surface or at an internal flaw, effective ly reduce the cross-sectional area. One final loa d, nominally as safe as similar earlier loads, caus

es a stress at the ultimate strength and a brittlelik e failure results. 6,52 Fatigue failure depends on the establishment and growth of crack planes through the material. An ything that aids either the initiation or the propag ation of these crack planes enhances fatigue. Fac tors that stimulate the formation of surface crack s are stress concentrations, surface imperfections attributable to material or finish, corrosion, and gross intensity of stress. The growth rate of a cra ck is a function of both the number and the inten sity of the loading cycles in a given period. It is i mportant to note that the effect of loading is cum ulative. Resting periods do not allow the metal t o regain strength or repair cracks. 6,52 Mechanical structures, unlike bones, lack physiologic system s, which respond to stress levels; thus there is no remodeling or hypertrophy to meet the new dem ands.40 Nor is there a means to conserve and ref orm available raw materials by selective atrophy of structures when they are no longer needed. The ability of a material to resist fatigue failure i s demonstrated by the relation of allowable stres s to the number of cycles of that stress that can b e tolerated. Curves for a particular steel and a pa rticular aluminum are shown in Fig. 2-17. Altho ugh they represent the most likely lifetime of a material, usually a considerable scatter of actual data is found. Endurance limit. Ferrous alloys typically can wi thstand some level of stress for an unlimited nu mber of cycles. The greatest repetitive stress for which the material does not fail is called the end urance limit. This is reached where the curve of stress versus cycles becomes horizontal. If a ferr ous alloy can withstand 106 cycles, it will probabl y withstand an indefinitely larger number of simi lar cycles. This indefinite "life" is not true for other metals, especially aluminum alloys. In these the nominal tensile endurance limit is defined as the greatest tensile stress that would allow 5 X 108 (or 500 m illion) cycles. Actually, it is possible to cause fat igue failure in aluminum alloys at the nominal e ndurance limit simply by increasing the number of cycles. Because the curve of tolerable stress v ersus number of cycles is so nearly horizontal at a large number of cycles, only a small reduction in stress will prolong the probable useful life by 10, 100, or even 1000 times. Generally the endurance limit of a metal is betw een 30% and 50% of its yield stress. Any tensile stress of higher value repeatedly applied will ind uce fatigue failure. Because notches, roughness, or c r rosion are such serious sources of increase d stressaccelerated fatigue failure, much attentio n should be given to their prevention in orthoses and other str uctures that experience critical loading under constr aints of weight and bulk; such attention is more effe ctive than searching for nominally stronger material

s. Stress in complex loading situations Bending. The most common and crucial comple x stress condition existing in orthotic devices is bending. The stresses associated with bending lo ads are combinations of shear, compression, and tension. To understand the stress condition caused by ben ding, we can examine a beam of uniform cross s ection subjected to bending forces on each end (Fig. 2-18). By isolating a portion of the structur e (a "free body" in engineering terms) and analys ing the external forces and moments acting on o ne surface (A), we can discern the resultant inter nal reaction on it. If a condition of equilibrium e xists, the resultant of the internal reaction must b e equal to the moment applied to the beam. If thi s were not true, the body would not be in equilib rium and would tend to spin. This internal reacti on moment achieved by a stress distribution co nsisting of noth tension and compression (Fig. 219). The creater the internal reaction moment (b ending monent), the greater are these stresses. M aximum compression occurs on the cross section near the surface on the concave side of the curv e. Maxittum tension occurs opposite this, on the convex surface. The normal stress distribution in bending of any beam varies evenly from maximum tension at on e surface to maximum compression at the opposi te. The stresses are 0 (changing from tension to c ompression) at the neutral axis. The amount of st ress in a beam depends on the amount and distri bution of material in the cross-sectional area. Th e parameter that measures this is called the secti on modulus (z). For instance, a three-flanged nai l has a much lower section modulus than does an 1 beam of similar size (Fig. 2-20). The 1 shape p laces more material farther from the neutral axis and as a result the material can sustain a higher b ending moment perpendicular to that plane. The 1 beam has a lower modulus, however, for bendi ng across its face than does the nail. The use of s uch special shapes requires knowledge as to the direction of the load and the magnitude. The greater the section modulus, the lower will b e the stress. The stress for a bending load is alwa ys maximum at the outermost point on the cross section. Usually, a beam breaks because of failur e of the outermost fiber with subsequent progres sive ruptures of the succeeding fibers. For an asy mmetric cross section like the tibia, the maximu m compressive stress may be less than the maxi mum tensile stress because the distance to the ou termost fibers in compression is less (Fig. 2-21). Since a knowledge of bending stresses is useful in understan ding the mechanics of orthoses, this concept will be further examined by separate study of the variables of bending moment and section modulus. The value of the internal bending moment (M) i

n any section of a cantilever beam or a beam sup ported at the ends and bearing a single concentra ted load is the product of a force and a distance. This means that given the same transverse force acting on one end of the beam, the internal mom ent and thus the stress at any section distal to the force will vary with the length of the beam. For equal sections, a simple beam that is twice as lon g will have twice,the maximum resulting stress s ince its maximum moment at its center is twice t he value of the shorter beam (Fig. 2-22). The section modulus is an important parameter i n consideration of the strength of beams. The se ction modulus is a property of the cross-sectiona l area that takes into account not only the total a mount of area but also the disposition of the area with respect to the neutral axis. Beams may possess the same area but have wide ly differing sectional moduli. Three beams with t he same area, 4 cm2 , but with various distributio ns of material demonstrate different sectional m oduli. For a beam positioned as a plank (Fig. 2-2 3, A) the section modulus is 0.667 cm3. When th e same area is formed into a square shape (Fig. 2 -23, B), the section modulus will be 1.333 cm 3. I f the beam is turned up on edge as a joist (Fig. 223, C), the section modulus increases to 2.667 c m3 . There is a factor of 4 between the first and l ast illustration. The value of the section modulus (calculated as the base multiplied by the square of the height divided by 6 for rectangular cross s ections) is a measure of the strength of the beam. In other words, for a given bending moment the beam with a maximum-value section modulus w ill have the minimum bending stress and thus the least tendency to fail. A beam on edge will supp ort a larger bending moment than can be support ed by the same beam oriented flat. Normal stress is not the only type of stress produ ced in a beam under bending. For a section of a centrally loaded beam, near the center force (Fi g. 2-24) there is both a moment and a shear forc e. Both the moment and the shear force are need ed to enable the beam to remain in equilibrium. The shear force (F) produces stresses whose dist ribution depends on the shape of the cross sectio n. For most applications, the bending shear stress is not critical; its magnitude is usually much lower than that of the bending tension and the bending co mpression stresses. Nevertheless the compromises b etween tension, compression, and shear illustrate th e problems facing a designer. For a given weight of beam the designer, confident of the direction of load ing, may attempt to move material outward from the neutral axis (e.g., as in a joist or an I beam) to mini mize tension and compression stresses. If material is moved too far, however, a deep narrow joist likely t o buckle or wrinkle in the center may result. The tw o planks, flanges of an exaggerated I beam, are conn ected by a thin membranelike web so overstressed i

n shear as to be nearly useless in connecting the two flanges for mutual support. The real orthosis may w ell have practical limitations of cosmesis, clothing d amage, or difficult fitting to the particular patient. T hus, in efforts to reduce stress, there are realistic lim its to changes in cross section. Torsional loading. When a body is subjected to a moment or torque tending to twist about its axi s, it is said to be subjected to torsion. As a result it undergoes a complex state of deformation and etress. An example is the solid cylinder subjecte d to torque (Fig. 2-25). For the portion of the cyl inder to the left of section A (isolated as a free b ody), the stress distribution must produce a resul tant moment equal to and opposite the net torque imposed on the left end of the cylinder. This mus t be true if this element of the body is to remain i n equilibrium. In addition, there can be no resulti ng axial or radial force since there are no compar able applied loads. The stress distribution that sa tisfies these criteria is thown in Fig. 2-25, B. It c an be seen that all the stresses on the cross sectio n are shear stresses. The shear stress is distribute d over the entire cross section A. The magnitude of the stress is proportional to the distance from t he center of the bar (with the maximum at the ou ter edge) and inversely proportional to the area moment of inertia (a measure of the distribution of the section area relative to the center point). In the human tibia subjected to torsional loading (Fig. 2-26), the shear stress generally increases li nearly with distance from the neutral axis along a given radius. However, a point on the surface f ar from the neutral axis of a triangular or other n oncircular shaft (and somewhat like the apex of t he triangular tibial section) has a lower shear stre ss from torsion than does a surface point near th e axis (like the flat portion of the triangle). The l ocal shear stress is analogous to the correspondin g slope of a soap bubble blown on a hole of the s ame section. The uniform slope of the bubble ed ge around the circumference of the round hole (li ke the uniform shear around the circumference o f Fig. 2-25) is obvious and can be used for calibr ation. Conversely, the irregular bubble on a squa re or triangular hole displays both gentle and ste ep slopes. 28 This paradoxical stress distribution leads to high shear stresses at the roots of keywa ys in shafts, at graft sites, or near other irregulari ties in the shafts, bones, or any structures subject to torsion. Because of changes in the shape of the bone and the distribution of bony material, the values of m aximum shear stress vary throughout the length of the bone. At the junction of the proximal three fourths and distal one fourth (section B in Fig. 226), the cross-sectional distribution produces a st ress approximately twice that at the proximal sec tion (A) even though the cortical bone is thicker at the distal section. The torsional fracture of the tibia would be expected to occur at the distal sect ion, as is commonly observed.

If a ferrous alloy rod is twisted until it breaks, th e failure plane will be noted to lie perpendicular to the axis of loading, in the plane of maximal sh ear stress. Objects such as cylinders, cylindrical and square tubes, and tibias have closed cross sections. 1 be ams, channels, and C sections all have open secti ons. Opening a closed section (e.g., cutting a slot in a tibia) drastically decreases the ability of the structure to carry torsional loads by altering the s tress distribution and hence reducing the strength of the section. This can be seen by comparing th e stress distributions in closed and open sections subjected to torsion (Fig. 2-27). In the closed sec tion the stress distribution is such that all stresses have counterclockwise moments about the centr al axis. Thus they all effectively contribute to the equalization of the applied torque. In the open se ction, however, the shear stresses are not all simi larly directed. The moment produced by the mor e central shear stresses is in the same direction a s the applied torque and is additive. Since the ap plied torque must be resisted by the net moment of the induced stresses, the stresses along the ext erior are greater than those inside. Thus, in resist ing the same torque, much larger stresses are pro duced in the open than in the closed section. She ar stresses under torsional loading are associated with equivalent tensile and compressive stresses on diagonal planes, leading to spiral failures of b rittle materials, particularly under shock loading. In the case of the open section under torsion, lar ge shear, tensile, and compressive stresses are de veloped in response to the torque. Such clinical problems as fractures of donor tibias or of other bones opened by cysts and tumors illustrate failu res of open sections subjected to torsion. Concepts of rigidity, including elastic materia l properties and section and length considerat ions. The section modulus of a structure relates i ts strength to the distribution of material through out its cross section. In addition to a considerati on f strength, which is a measure of load-carryin g capacity, we are also interested in the rigidity of a structure. Rigidity is a measure of the amou nt of load needed to produce deformation and is related to the area moment of inertia. The rigidit y of a beam is the ratio of the applied load to the deflection. Thus the rigidity of a beam might be 5000 N/cm, meaning that 5000 newtons are requ ired to produce 1 cm of deformation at the cente r. It might be that the beam would fail at 1000 N of load and 0.2 cm deflection, but this would not alter our statement of rigidity. The more rigid th e structure, the greater must be the load to produ ce a given deformation. Several factors influence the rigidity of beams: e lastic modulus of the material, area moment of i nertia of the cross section. and length of the bea m. The area moment of inertia is another measur e of the distribution and amount of cross-section

al area. For rectangles it is the base multiplied b y the cube of the height divided by 12. Thus a st eel orthosis (E = 207,000 MN/m2) is more rigid t han an aluminum one (E = 70,000 MN/m2) of th e same size and shape. In the same material, dou bling the thickness of vertical strut (Fig. 2-28) w ill increase its anteroposterior bending rigidity b y a factor of 2 and in its mediolateral by a factor of 8 (because the moment of inertia depends on the cube of the he ight). If the length of the beam is halved, its rigi dity will increase by a factor of 8. Maximum rigidity is not necessarily a desirable goal particulariv if shock loading must be resiste d. If a structure is too rigid, it will not deflect mu ch and therefore will not absorb much energy be fore it Energy concepts in loading Elastic and plastic strain energy. If a beam is a i ductile material and a sufficient load is made of ductile material and a sufficient load is placed o n it. the load deformation curve obtained will be as shown in Fig. 2-29. The left-hand portion of the curve (O-Q) represe nt the familiar reversible linear elastic deflection induced in the material by the bending stresses. Eventually the outermost fiber yields at the secti on with maximum moment; that is, it continues t o deform without any increase in stress and per manent dislocation occurs in the crystalline struc ture. As the loading is continued, the fibers belo w the outermost one also yield. If the load is no w removed, a permanent change in shape will be noted. This is the mechanism used by the orthoti st to deform a component with bending irons. If the load is increased, eventually a point is reache d at which all fibers at this critical section yield and, under constant load, the beam continues to deform. Such deformation may continue until ru pture occurs (point S). The amount of elongation that a simple tension specimen of any material can undergo before ruptur e is often used as a measure of the ductility of the m aterial. For example, 316 stainless steel elongates 2 7% whereas chemically pure titanium elongates as much as 36%. Influences of energy of failure in columns. En ergy concepts are also useful for understanding f ailures in columnar structures. A column is a lon g slender structure loaded axially. When an ident ical structure is loaded as a beam (transverse loa d), the amount of energy that can be absorbed is proportional to the deflection (as long as no per manent [plastic] deformation occurs). Columns behave in a nonlinear way. Fig. 2-30, A, illustrates the deformation produce d by an axial load on a column. The amount of e nergy absorbed in this manner is also the area un der the load-deformation curve. If the column co uld remain straight, the energy would increase w

ith the load in a linear manner (O-Q in Fig. 2-30, C). There are other shapes, however, that the col umn will assume if the load continues to increas e. One is illustrated in Fig. 2-30, B. The load def ormation characteristics for this configuration ar e reflected in 0S-T. The initial straight-line porti on (O-R) represents the erect column, which is b eing loaded axially while remaining in a linear c onfiguration. In region R-S the column suddenly bows. At point S the total energy is less than at R. Energy is lost in the damping of vibration whe n the column snaps from one position to another. Actually, in practical cases, if the column reache s the energy storage level indicated at point R, an y small disturbance will drastically change its co nfiguration (to that at 1), a state of pronounced b owing. MATERIALS Steel Steel is the general term used to describe a famil y of alloys produced by removal of impurities fr om pig iron. It is abundant, relatively cheap, and avail able in various alloyed and heat-treated stat es. The basic advantages that can be incorporated in to steel are high strength, high rigidity, consider able ductility, long fatigue life, and ease of fabri cation and availability. Among its disadvantages are high density, need for expensive alloying to prevent corrosion, and poor surface wear charact eristics in bearings. Steels may be divided into three classes: carbon, low-alloy, and high-alloy. The carbon steels hav e a variety of uses, ranging from structural parts to cutting tools. Low-alloy steels are used when higher strength is required together with moderat e ductility. High-alloy steels are used for high-st rength applications and are the most corrosion re sistant. Mechanical characteristics Carbon steel. At low concentrations of carbon (0.05% to 0.10%), steel is very ductile but has a low yield strength. As the percentage of carbon increase s, the ductility decreases and the yield strength incre ases. At any particular level of carbon content, appr opriate heat treatment can also increase strength at t he cost of reducing ductility. The actual yield strength of carbon steel may var y from 207 MN/m 2 (30,000 psi) to 860 MN/M2 (125,000 psi) depending on carbon content and h eat treatment. The corresponding range in ductili ty is from approximately 40% to less than 10%, Low-alloy steels. Low-alloy steels have mechani cal properties that fall between those of the carb on steels and the high-alloy steels. Their tensile yields are between 345 and 380 MN/m 2 (50,000 to 55,000 psi), with ductility of approximately 2 5%. They thus are not often used for medical pro ducts. High-alloy steels. When corrosion resistance is not a requirement, high-alloy steels can be obtai

ned with extremely high strength-to-weight ratio s. These steels are well suited for structures subj ected to large repetitive loads. They are more ex pensive than low-carbon steels and also more dif ficult to fabricate. They can be heat treated or co ld worked to improve their strength levels even f urther. If corrosion resistance is also a requirement for a particular application, there are three types of .St ainless steel" of increasing corrosion resistance f rom which to choose: series 400 iron-chromium stainless steels (hardenable only by cold-workin g), series 400 iron-chromium stainless steels (of slightly different composition that can be harden ed by heat treatment), and series 300 iron-chrom ium-nickel stainless steels. Cold-worked iron-ehromium alloys. Used mai nly in industrial applications requiring moderate corrosion resistance without electroplating, these materials might be suitable for such medical app lications as deep-drawn instrument trays. Heat-treatable iron-chromium alloys. Containi ng up to 16% chromium, possessing considerabl y greater corrosion resistance, and capable of har dening by heat treatment, these alloys are widely used in forceps, suture needles, and other surgica l instruments. Iron-chromium-nickel alloys. The addition of n ickel provides even greater corrosion resistance i n all temperature ranges. These alloys cannot be heat treated to increase hardness or strength, but coldworking can be used to improve these prope rties. An early alloy of 18% chromium and 8% n ickel is widely known for many industrial and so me medical applications. Surgical implants are t ypically 17% to 19% chromium, 12% to 14% ni ckel, and 2% to 3% molybdenum. When such ste els are made with less than 0.03% carbon (c. g., 316L), they are even more resistant to corrosion. Aluminum In both its pure and its alloyed forms aluminum i s a useful metal because of its low density, mode rate corrosion resistance, and relatively high stre ngth. Unfortunately, the last two properties are u sually optimized at the expense of each other: in creased strength often results in decreased corros ion resistance. Pure aluminum is a very ductile low-strength ma terial (34.5 MN/m 2 , 5000 psi yield) with unlim ited uses. Because of the oxide that rapidly form s on its surface, progressive oxidation cannot tak e place. For practical purposes, the pure aluminu m is "corrosion resistant." This resistance is ofte n obtained in alloys by covering with pure alumi num (Alclad). However, hydrochloric acid and a lkalis dissolve the oxide film on aluminum surfa ces and allow rapid material degradation. Theref ore the corrosion resistance of pure aluminum ap plies only to atmospheric conditions. Aluminum is high reactive in physiologic solutions. Aluminum alloys may be divided into two classe s: those used for casting and those that are wrou ght.

Casting aluminum. Casting aluminum may be a lloyed with copper, silicon, and/or magnesium. These have low to moderate strengths (131 to 16 5 MN/m 2, 19,000 to 24,000 psi yield) and low d uctilities (0.5% to 1.3%). Wrought aluminum. Wrought aluminum may e xist in sheet, bar, tube, or extruded form. Some members of this class can be hardened, and their mechanical properties improved, by precipitatio n of copper at slippage planes, often by heat treat ment. Such precipitation takes place spontaneous ly at room temperature for certain alloys and at moderate temperatures for others. In the case of 2024-T3 alloy, often used in ortho ses, moderate temperature (1750 to 2050 C, 350 0 to 400' F) causes the previously precipitated co pper to be dissolved and allows the crystal plane s to slide over each other relatively easily, even f or a short time after the aluminum alloy is rapidl y quenched. The alloy can be conveniently shape d and then rehardened by the work-hardening du ring shaping as well as by aging within a few (12 to 24) hours at room temperature and more rapidly at moderately el evated temperatures. The copper is again precipitate d to "key" the crystal planes, restoring the yield stre ngth and resistance to further deformation. This beh avior seems paradoxical to persons familiar only wit h carbon steels, for which heating to high temperatu res and then rapidly quenching in water will cause s ubstantial permanent increases in strength and hardn ess (e.g., heat-treating a chisel blade). Heating well beyond 200C will cause permanent annealing with low strength but high ductility (e.g., at 365C, 600 F, about 10% of the tensile and yield strengths but more than triple the elongation noted in material kep t at room temperature or heated to only 175C). Cold-working can also be used to improve the m echanical properties of wrought aluminum alloy s. There are two groups of these alloys: the MnMg and the Cu-Si-Mn-Mg. Heat treatment and c oldworking can produce moderate yield strength s (up to 483 MN/m2 , 70,000 psi) but will result i n low ductilities at these levels. Comparisons. There are several similarities and dissimilarities between aluminum and steel alloy s. The elastic modulus of aluminum alloys is 69,00 0 MN/m2 whereas that of steel alloys is 207,000 MN/m2 . This means that for the same shape and loading, aluminum structures will elastically defl ect three times more than steel structures. Another basic difference is that steel has an endu rance limit under repeated or fatigue loading wh ereas aluminum does not. This means that if the l oading conditions are known a steel structure ca n be designed to allow for infinite life. An alumi num structure, however, is eventually subject to fatigue failure as long as it continues to be loade d. Fortunately, as noted earlier, at a practical hig h number of load cycles a small decrease in stres s will allow a tenfold increase in life. Finally, it can be said that "high-strength" alumi

num alloys generally demonstrate much greater i ncreases in static strength than in fatigue loading strength at 1 million to 500 million cycles. Furth ermore, these alloys often are heat treated or wor khardened to greater hardness but lower ductility and typically are much more sensitive to notche s; thus they are not as useful in practical orthotic s applications as their static strengths might indi cate. Titanium and magnesium Titanium. Titanium has been commercially avai lable for about 35 years, yet already it is an extre mely important metal. Its alloys are stronger tha n those of aluminum and are comparable in stren gth to many steels, it demonstrates more corrosio n resistance than aluminum alloys and steel do, a nd (as an added benefit) it is only 60% as dense as steel. However, it is more difficult to machine than aluminum or steel although assembly of pre fabricated components may reduce or eliminate t his disadvantage for small facilities. The elastic modulus of titanium (116,200 MN/m 2 ) is higher than that of aluminum but only slight ly more than half that of steel. Titanium will abs orb about twice as much energy before yielding as a comparable strength of steel will. Unlike other metals, titanium is structurally usef ul in its commercially pure form. Depending on heat treatment and working, it is available with y ield strengths of 210 to 490 MN/m2 (30,000 to 7 0,000 psi), with correspondingly inverse ductiliti es of 25% to 15%. As with steel and aluminum a lloys, titanium is weldable. Although some steels can he welded in an air atmosphere, both titaniu m and aluminum alloys must be welded with eit her a tungsten are and inert gas (TIG) or a metal are and inert gas (MIG). In either system the iner t gas is usually argon or helium. Titanium alloys contain a variety of elements: F e, N, Pd, AI, Mn, Sn, Mo, Zr, and V. Alloying el ements are used to increase workability, machin ability, strength, and biocompatibility. A titaniu m alloy containing 6% AI and 4% V is used as a surgical implant. In most cases, however, titaniu m and its alloys can be formed and fabricated by the same processes as used for aluminum alloys and for steel. The major exception is casting. Tit anium is a difficult material to cast. Magnesium. Magnesium is considerably lighter than titanium and somewhat lighter than aluminu m, and its modulus of elasticity is even lower tha n that of aluminum. However, screw threads are likely to be stripped unless special precautions ar e taken. Magnesium bars or castings are used for some special cases in a variety of industries, but magnesium has had relatively little application i n orthotics. Plastics There are two major categories of plastics-therm osetting, which require application of heat to cur

e or harden but which do not soften upon further heating, and thermoplastic, which will soften eac h time the temperature is raised but harden upon lowering of the temperature. Thermosetting plastics. Thermosetting plastics are production-molded from phenol, urea, or mel amine and are widely used in industry. In prosth etics, however, and to a lesser extent in orthotic s, custom-molded low-pressure laminates are ma de from polyester or epoxy resins (or, increasing ly, from thermoplastic acrylic resins). The original and still widely used variety is base d on phenol-formaldehyde, which is supplied as a powder and is formed at high temperature (149 C, 300F) and pressure (13.8 MN/m2 , 2000 ps i). The resulting tensile properties will vary with the filler material but range from 27.6 to 82.7 M N/m2 (4000 to 12,000 psi). For improved structur al properties the phenol-formaldehyde may be "f illed" with chopped fibers or may be used as a re sin to bind materials like paper or cloth into stru ctural shapes. Such laminates have improved me chanical properties but are also more hygroscopi c. Because of the expensive mold needed, pheno l-formaldehyde plastics are better suited for mas s production. The second important class of thermosetting plas tics, urea-formaldehyde resins, do not differ in th eir fabrication and properties significantly from t he phenol-formaldehyde plastics except that they are less expensive, may be colored, and are mod erately resistant to water. These materials are av ailable in sheet and bar form, but more complex structural shapes must be fabricated by means of expensive dies and complex molding machinery. For decades (since World War II) polyester resin s have been used to form low-pressure thermoset ting laminated prostheses and, to a lesser extent, orthoses. Epoxy resins, introduced about 1948, were used particularly in Europe. Because little or no pressure is required to cure these materials (typically as laminates), larger sections can be fa bricated and with less expensive Tools. They are suitable for custom molding over a plaster model and are used as the binding resin in a two-phase l aminate material (e.g., woven sheets or strips of glass fiber, bundles of parallel glass fibers [term ed roving]. and knitted Dacron polyester stockin et). Epoxy is also used as a very strong glue. Exothermic reactions after mixing of resin comp onents and catalysts or promoters permit "bench Curing" of individual laminated sockets, orthose s, etc. Complete polymerization, however, is nee ded to assure strength and to avoid dermatitis fro m contact with uncured resin. Thermoplastics. The thermoplastics can be sub divided into (1) polyvinyl resins, (2) polyethylen e and polypropylene, and (3) polycarbonate. The major composition used commercially in the rmoplastics, the polyvinyl resins, includes polyvi nyl chloride (PVC), polyvinyl chloride acetate, p olyvinyl alcohol (PVA), and polyvinyl acetate. T he PVC group consists of tough, hard materials t

hat usually require a plasticizer or softener. Amo ng the uses for these materials are leather substit utes, piping and tubing, and small complex struc tural components. All structural fabrications req uire special tooling and injection -molding equip ment. Tubelike shapes may be extruded, but the t ooling is expensive. Commercial PVC tubing (lo w cost in stock sizes) can be cut for specific requ irements and, if necessary, heated and bent for ra pid assembly of endoskeletal prostheses. PVC an d PVA sheets and bags are widely used for plasti c laminating in prosthetics and orthotics. Becaus e PVA can be softened by dampening, a conical sleeve may be stretched over a relatively comple x plaster model of a residual or paralyzed limb. Other important thermoplastic composit ions are polyethylene and polypropylene. Both t hese material are highly stable and resistant to w ater and solvents. They are easily formed and ha ve many medical uses, including (for polyethyle ne) internal prostheses and for polypropylene, be cause of its in definitely long fatigue life under r epeated loading) orthotic hings joints. Polyethyle ne, polypropylene, and (more recently) polycarb onate and ionomer are being used increasingly f or orthotic structures of new design and for prost hetic sockets. A heated and softened sheet is sha ped on a plaster model by vacuum molding, with the thicknesses skillfully controlled and the edge s trimmed and polished. Although polyethylene and polypropylene are semicrystalline materials at body temperature and not transparent, the thic knesses and grades used in orthotics are transluc ent. By contrast, polycarbonate, ionomer, and po lymethyl methacrylate are transparent. allowing better detection of pressure spots and a less cons picuous appearance. Special care must be taken to dry polycarbonate before molding, to prevent crazing, with reductio n of its transparency and exceptional strength. P olycarbonate is very stiff. Recently ionomer, a th ermoplastic that does not need to be dried before molding, has been used increasingly for orthoses despite its lower ultimate tensile strength. It is re asonably transparent but much more flexible. As we have seen, yielding is sometimes equated wit h failure, but in many cases the yielding of plasti c under emergency circumstances will minimize other dama ge, particularly if the ultimate strength is not reache d and if, as with some metals and thermoplastics, th e device can be restored to its original shape. Table 2-1559 compares physical properties of selected ther moplastics used in orthoses. Polymethyl methacrylate has long been available and occasionally used for upper-limb splints, but it is relatively weak. Acrylonitrile-butadiene-styr ene (ABS) combines high rigidity with high tens ile and flexural yield strengths and high impact s trength. It is available in many colors and is wid ely used commercially for casings and housings. In orthotics it is used for spinal orthoses and cust om-molded wheelchair seats.

Nylon is a strong, tough, abrasion-resistant ther moplastic but has the disadvantage of absorbing water. In addition, it is relatively expensive com pared to some materials with similar properties. Low-cost nylon washers, however, have been us ed without lubrication in orthotic joints, particul arly with aluminum bars.57 The ability to form an orthosis or a prosthetic so cket safely, comfortably, and rapidly directly on the body of the patient has long been a goal. It is also desirable to be able to modify the device in certain areas to relieve pressure spots, to change alignment slightly, or to accommodate small am ounts of growth or atrophy. By contrast, the devi ce should not be affected by accidental contact with a steam radiator, storage in the trunk of an a utomobile on a hot day, or exposure to various c hemicals in the environment. Synthetic balata (P olysar)61 and a perforated version (Orthoplast)36,3 7 have undergone considerable development. Th ey can be heated in boiling water until soft and t hen molded on the body, either directly on the sk in or over thin stockinet. Rapid evaporation of th e film of water and radiation during transfer to th e body apparently cool the surface to a tolerable level. The very low thermal diffusivity of the ma terial (related to its low density and low thermal conductivity) prevents rapid heat transfer from d eeper inner layers to the interior and exterior sur faces, avoiding pain to the patient and allowing t he orthotist to continue brief molding of the soft ened thermoplastic with the hands followed by st eady support during several minutes of hardenin g. While wet and heated, the material sticks to it self, which is desirable for seams. Surfaces that s hould not adhere can he sprayed with separating fluid. Temporary prosthetic sockets and fracture braces have been made from Polysar, and Orthoplast is used extensively for temp orary upper-limb splints. Although some process si milar to vulcanization would seem desirable to incre ase strength and retain shape after forming, another worthwhile objective is retaining the ability to make repeated small additional adjustments. Rubbers. The term rubber is used to denote the family of natural and artificial elastomers that in cludes, along with natural rubber, butyl rubber, p olysulfide rubbers, neoprene, nitrile rubbers, and GR-S butadiene-styrene copolymer. Rubber is used whenever large elastic deformati on (up to 3000% of the original length of the ma terial) is required with relatively low force level s. Because most rubbers are almost perfectly ela stic, there is only limited energy loss by hysteres is or internal friction. The nonlinear stress-strain characteristics of rubber can provide in a finishe d structure a large excursion at relative low force s, then more rapidly increasing forces, and finall y such large forces as to block further motion. R ubber is a much better elastic energy absorber, o n a weight or volume basis, than any metal. Thus

it can be effective in bumpers, elastic straps, etc. The skid resistance of cane or crutch tips on wet pavements or ice depends on high flexibility and hysteresis. 32 Natural rubber and some styrene-b utadiene compounds, preferably with oil extensi on of either, would be most suitable around the f reezing temperature of water. Besides being resistant to wear, natural rubber h as excellent tensile properties. Its resistance to c old, flexing, and aging is also excellent. Howeve r, it is not impervious to sunlight or to most oils or solvents. Butyl rubber offers improved resista nce to ~unlight and solvents but lacks the high te nsile ~strength or wear resistance of natural rubb er. Because of the wide variety of properties that ca n be produced in rubber by compounding, it is of ten possible to produce a material that is well sui ted for a particular application. Cellular rubbers and plastics. Numerous cellula r rubbers and plastics (e.g., polyurethane, polyst yrene, polyethylene, polypropylene some capabl e of custom molding while comfortably hot) are used in prosthetics and orthotics. The softer grad es are best for padding, but firmer and more den se varieties are also being used increasingly for c osmetic covers of endoskeletal prostheses or eve n as structural elements. Some types have interc onnecting pores, allowing absorption and passag e of fluids, gases, or vapors. These open-cell mat erials, however, can create hygienic problems if perspiration or debris accumulates in the pores. Other types, closed-cell forms, have individual g as-filled cells or "bubbles" that do not interconne ct. When cellular plastic is molded, a smooth and re latively tough skin typically is formed against th e wall of the mold that is often an advantage. Bl ocks cut from cellular material, and perhaps furt her sanded to desired shape, have rough surfaces with randomly distributed cavities of remaining pores. In some cases these surfaces can be sealed and smoothed by painting with latex. For structu ral uses one or more layers of plastic laminate m ay be added. DESIGN CONSIDERATIONS Practical and economic considerations In selecting specific materials and components f or the various portions of an orthosis, it is necess ary to consider practical and economic factors. S afety, case of working, compatibility of prefabri cated components, ease of adjustment during fitt ing or subsequent use, and feasibility of attachm ent are aspects. In any portion that comes in contact with the bod y, safety is essential. There must be no toxicity, allergenic tendency, or mechanical irritation. A material such as fiberglass may be used for reinf orcement of a laminate if it is buried in the matri x, but special care must be taken to reseal the fib er ends exposed by grinding during trimming an d fitting. To avoid toxic or allergic reactions to u ncured components of the resin, curing of plastic

s must be complete. During the initial use of plas tic laminates in prosthetics, it was reported by a few facilities that skin irritation resulted from fre e monomers left after incomplete curing. The ch aracteristic odor of the monomer was readily det ected near the supposedly cured laminate. With adequate care, however, these difficulties were o vercome, If any doubt remains, heating the finis hed laminate briefly with a heat lamp is effectiv e. With tile current interest in forming prosthetic sockets and orthotic devices directly on the patie nt's body, not only the toxicity of base materials, plasticizers, or solvents but also their workabilit y at tolerable temperatures are factors. Ease of working with available facilities is' an i mportant practical consideration. The necessity of forming orthotic structures to fit each patient i mposes unusual requirements not typically foun d in many industrial operations. Conventional molds, dies, and punches used in mass production of identical parts are sometimes ap propriate for prefabricated components of orthotic d evices. These devices are typically produced in a fe w stock sizes, perhaps capable of being cut to length or of being slightly adjusted further to shape; but an y part that fits the body must be formed to the indivi dual. A wide variety of straps, buckle attachments, a nd similar parts is available from a few central man ufacturers as inexpensive prefabricated elements. Prefabricated ankle or knee joints have been avai lable for decades and increasingly widely used a fter the mid-1950s, partly because of improved c ontrol of tolerances and quality. Probably the gre atest incentives were the economic savings from the reduction in time required of skilled labor an d the possibility of more rapid delivery to the pat ient.'s' In some designs the "joint head" is a sepa rate element adapted for attachment to a bar or o ther structural element by screws or rivets. Quite commonly the joint head is delivered by the man ufacturer as an integral piece with a relatively lo ng straight bar that can be formed to shape and c ut to the appropriate length for the individual pat ient by the local orthotics facility. Metal bars or similar structures typically are adjusted by using bending irons to strain the metal into the plastic r egion, leaving a permanent set when this load is removed. By contrast with practice common prio r to 1950, forging of metal bars at high temperat ure now seldom occurs in local orthotics facilitie s. With the proliferation of new designs of orthose s, the conventional prefabricated components of the 1960s will probably continue to decrease in usefulness. Some joints will be replaced entirely by the bending of selected portions of the structu re. Other prefabricated components, redesigned t o attach readily and securely to plastic laminate, thermoplastic, or composite structures, will conti nue to cut labor costs and improve service. Some of the cuffs, shells, or other portions in co

ntact with the patient's body are now prefabricat ed in a few sizes and shapes. They can then be sl ightly distorted by straps or laces or more extens ively modified (as with a heat gun in the case of thermoplastics or postforming thermosetting pla stic laminates). Simple adjustments during daily wear should be possible and are provided preferably by Velcro s traps. 36 Small adjustments can then be easily m ade, as opposed to the substantial amount of man ipulation needed to move a conventional buckle between successive holes in a belt. Preferably a s trap should be "snubbed," or passed through a lo op fastened by another strap or a billet to the opp osite structure and then laid back on itself and th e loose end attached to the original portion by m ating Velcro elements. Just as in a rope-and-pull ey system, the load on each end and thus the she ar load on the Velcro are cut in half, compared w ith the situation that exists when mating straps o verlap from opposite sides of the structure. Buckles with tongues and perforated straps are a lso widely used and are adequate for adjustments requiring substantial steps, but they are especiall y appropriate for repeated attachment (by a dextr ous patient) or for opening and closing at a relati vely fixed position. Buckles capable of sliding a djustment along a fabric strap are frequently use d to modify the length of a harness or suspension. Traditionally the longitudinal bars or uprights of lower-limb orthoses for children have consisted of two portions fastened together by several scre ws. The length could be incrementally modified to accommodate growth by use of the uniform di stance between screw holes in one of the bars. A few of the newer orthoses lack this adjustability. Thermoplastic materials may allow for slight mo dification of diameter or shape to fit a changing body portion, but they do not seem appropriate f or accommodating to longitudinal growth. Some sort of telescoping construction may be needed. Attachments of orthotic components may be ma de in a variety of ways. As we have seen, an occ asional material like synthetic balata (Orthoplast or Polysar 36,61) may stick to itself under certai n conditions, such as when it is hot and wet. Ind eed, release agents must be applied to areas that are not supposed to adhere when they come into contact during the construction or fitting process es. Some resins, particularly the epoxies, can be used effectively not only for laminating but also as cements. Metal joint heads may be welded by electric arc or gas flame to given an integral met al bond to adjoining upright bars. Brazing or sol dering provides a weaker metal-to-metal connect ion by a bond that melts at a much lower temper ature than the major structural metal. Some thermoplastic sheet materials can be weld ed with a slender rod of the same material. 17 Th e abutting edges are beveled to leave a V-shaped groove to be filled with the heated end of the ro d. Skill is needed to fuse edges and rod into a sin gle strong sheet.

Frequently parts are attached temporarily by a fe w light screws or rivets before the fitting proces s. Then more secure connection in the desired ali gnment is made by additional heavier screws or rivets or by brazing or welding. Composite structures are considerably more com plex than those of a single material. It can be de monstrated that there will necessarily be loading directly proportional to the respective moduli of elasticity if two or more different materials are u sed in parallel with equal deflections. Suppose, f or example, that a rigid frame supports a relative ly rigid loading bar (constrained to remain parall el) by a stiff high-modulus steel wire and a relati vely flexible low-modulus rubber band. The stee l wire (with but microscopic deflection) will carr y almost all the load whereas the rubber band (st retching the same slight amount) supports only a trivial share of the total load. Conversely, of cou rse, if the bar is free to change angular position a nd the flexible and stiff supports carry equal loa ds the flexible support will deform much more a nd the bar will no longer be parallel to the frame. In an important but less dramatic case, a strip of laminate or composite structure under tension ca rries most of the load on rather stiff fabric, stiffe r fiberglass, or much stiffer boron or graphite fib ers whereas the low-modulus resin matrix carrie s relatively little load. The transfer of load, even between two components respectively stiff and f lexible, in a single composite material or especia lly in a more complex structure forced to deform as a whole, may he complicated and involves sh earing stresses at the interfaces. Such transfer ca n be visualized by imagining structures of chains and springs connected by bars or beams. There are also stresses within structures subject t o external loading near sudden changes of stiffne ss. It is well known that these can concentrate at notches or around holes; it is equally true, thoug h perhaps less obvious, that stress can also conce ntrate in the neighborhood of reinforcements, alt hough the relative distributions of tension, comp ression, and shear stresses will differ between co nditions of weakness and reinforcement. Donnel l18 studied the stress concentrations around ellipti c discontinuities in edge-loaded sheets. All disco ntinuities, whether holes, weaknesses, or reinfor cements, showed significant stress concentration s. This analysis also has implications (as Bennett 8 has shown) for stresses in fleshy areas near the brim of a prosthetic socket or when an orthotic c uff impinges on flesh. In addition, Bennett at al.9 have shown that either compression stress or she ar stress reduces circulation but that shear stress is half as effective as compression in reducing sk in blood flow. The gross properties of a structure, a composite, a laminate, or a foam may be quite different fro m those of a solid sample of the individual comp onent materials and may differ for various types

of loading. In a beam, for example, a component with high strength and modulus of elasticity in te nsion may carry most of the load and determine most of the stiffness on the side loaded in tensio n. This is a common situation with the steel rods in a reinforced concrete beam. In a plastic comp osite or laminate, likewise, the graphite or glass fibers may carry most of the tensile or almost all of the compressive loading. The epoxy or polyes ter matrix, relatively weak when alone, transfers shear loads between fibers and provides such lat eral support that the long thin fibers do not buckl e at very low compressive loads as they would w hen they were isolated needles or threads of raw material before laminating. One of the advantage s of Dacron reinforcing fabric is its chemical sim ilarity to the polyester resin matrix, giving it a be tter shear bond. In a sponge or foam, especially with thin-walled interconnecting cells, the overall nominal stiffne ss of the gross material may be very low compar ed to that of a solid block of the basic material b ecause under load the thin walls are easily deflec ted and the cells (whether open or closed) readil y distorted. In a composite structure or material there may b e practical problems from major differences in th ermal expansion, absorption of moisture, or elect romechanical properties. Shear stresses will be c reated between two adhering materials of differi ng coefficients of thermal expansion if there are changes in temperature. Appreciable differences in absorption of moisture can lead to internal she ar stresses, cracking, or delaminating. Early plast ic laminates of cotton fabrics, for example, tende d to deteriorate if exposed to moisture, especiall y if the fabric ends were not resealed with resin after trimming of the brim or grinding during fitt ing. Dacron synthetic fabrics are more moisture resistant. Contact between dissimilar metals can lead to el ectrolytic corrosion in the presence of conductiv e fluids like perspiration, urine, or blood. Even sl ight corrosion may accelerate fatigue failure by i nitiating surface roughness to form stress-raising notches or by facilitating microscopic intergranu lar corrosion at the bottom of a crack that helps the crack to progres s. Many of these examples emphasize the role of s hear stress between two materials in a composite or laminate. The interrelationships of shear, tensi le, and compressive stresses in most practical loa ding situations involving a single material have a lready been noted. The ability to transmit shear s tresses is especially important, furthermore, in b onding composites and laminates together to ma ke maximum use of the separate properties of ea ch component. Fortunately, epoxy materials (wh ich first came into widespread notice in orthotics as "C-8"60 and since have been improved) are ex cellent adhesives when used alone and are tenaci ous matrices for composites and laminates.

An especially important precaution with epoxy i s to avoid skin contact with uncured resin both i n the workshop and in the clinical use of the fini shed appliance. Appropriate working habits and adequate ventilation are needed in the orthotics f acility. Thorough curing is crucial with epoxy. To use laminate or composite materials effective ly, it is necessary to understand the general conc epts of stress distribution. If (as in many practica l cases and especially during accidents) shock or impact loading is likely, a somewhat resilient or even plastically yielding energy-absorbing mater ial may be preferable to an extremely high-stren gth but stiff and brittle material. The stiff fibers i n composites will function effectively only if the ir bonds through the matrix are effective. Theref ore the matrix must inherently permit good bond s, the fibers must be clean, and bubbles or films must be avoided. Notches or scratches not only may accelerate fatigue failure but may cut some critical fibers situated close to the surface where they are especially needed to resist bending. The evaluation of new materials thus involves m uch more than a quick comparison of ultimate te nsile strength, the values most often quoted in pu blicity about new material. Compressive, shear, and fatigue strengths, stress-strain characteristic s, or at least data on yield strength and ductility, impact strength, corrosion properties, thermal ex pansion, electrochemical properties, and moistur e absorption are among the many factors to be c onsidered. For contact with the body, toxic and a llergenic properties and dermatologic aspects are crucial. Possibilities of working the material wit h currently available shop tools and especially of fitting individual patients with three-dimensional ly warped cuffs or bars must usually he consider ed even if the material is used in a prefabricated component. Cost per pound is of negligible conc ern. In view of these complexities, it is not surprising that individual, relatively small, orthotics laborat ories tend to be conservative in their choices of materials. Innovations and transfers of technolog ies have come largely from sponsored research l aboratories and some large university, governme nt, or private facilities. After substantial clinical trial, the use of these materials has been taught widely through the government-supported prosth etics and orthotics education programs. Special structures Joints and bearings. Traditionally orthotic struc tures have used numerous joints and bearings to simulate selected motions but prevent others. Ob viously restriction of motion leads to stresses., Pl antar flexion and dorsiflexion are often provided by ankle joints opposite the malleoli and on a lin e usually believed to be at the level of the upper ankle joint but perpendicular to the plane of prog ression. The desirability of a skewed upper ankle joint axis or an oblique lower axis for the subtala

r joint, as emphasized by Isman and Inman,30 has rarely been accepted. Often caliper joints below the heel represent tole rance of an obvious gross deviation from anatom ic position that, in the interests of simplicity, ma kes donning or removing the appliance and exch anging shoes easier and is economically more su itable for the patient. In selected cases, with stop s preventing significant plantar flexion and spast icity or other tightness restricting dorsiflexion, th e very limited range of angular motion can cause so little axial 11 pumping" of the cuffs and band s that the compromise with physiology is accept able. Similarly a relatively flexible posterior port ion of a one-piece molded thermoplastic foot-an kle orthosis (FAO) connecting the shoe insert wi th a posterior cuff high on the calf does not bend in a manner that truly matches motion about the ankle axis; but the discrepancy is justified becau se of the simplicity of the FAO. In a few designs a slip joint is provided between the calf cuff and a posterior vertical member. Knee joints, typically with locks at least on the l ateral bars, have been routinely provided in leg-t high orthoses (KAFOs).' They usually are on a si ngle axis through the approximate center of the f emoral condyles, which generally is a reasonable compromise with the moving instantaneous cent er of the human knee joint. Fortunately, during most of the ra nge of knee motion (including sitting positions), the human instantaneous center is near the center of the femoral condyles. 23 Because of the tolerance of tis sues to moderate compression and shear, small di screpancies between anatomic and mechanical joint s generally can be absorbed, as most clinicians appe ar to believe, without the complexities of polycentri c hinges. The location of the mechanical axis at the j oint space between femur and tibia, however, often i s criticized as being much too low, a location leadin g to considerable compression of the band just belo w the knee joints against the calf area during sitting and consequent restriction of return circulation. Joints traditionally were merely metal against m etal. About three decades ago there was great em phasis 57 on the possibility of reducing wear and decreasing squeaking noises by using bushings a nd washers (e.g., of nylon) between rubbing surf aces. Flexible structures as joints. Flexible structure s have served as joints for many decades, but ne w possibilities have arisen with plastics. The rec ent emphasis on thermoplastic hinges and on one -piece molded thermoplastic structures has reduc ed the problems of fitting and maintaining bearin gs, especially at the ankle. In recent years relatively thin but wide posterior thermoplastic beams or helically coiled strip 34 have been used as flexible structures both to resi st plantar flexion and to provide some lateral sta bility. The possible uses of such structures as ort hoses at levels other than the ankle have also bee n explored. The unusually great fatigue resistanc

e of polypropylene as a hinge probably has not b een fully exploited. Brakes and clutches. Mechanical brakes and clut ches and pneumatic or hydraulic resistance have occasionally been suggested to control the ankle, knee, or both .4, '~4 The UCLA functional long l eg brace combined biomechanical principles, car eful location of joints, ingenious use of reactions between flesh and cuffs, free plantar flexion, and hydraulic resistance to motion from plantar flexi on toward neutral and dorsiflexion. It allowed ca refully selected individuals with a single flail leg (usually from polio) to walk without a knee lock, but its indications were limited. This type of anal ysis, however, might well be applied to other pro blems in orthotics. Various polycentric linkages have also been sug gested to allow knee motion during swing phase but provide stability in stance phase. As with bra kes and clutches, most of these devices have bee n limited by their bulkiness near an already bulk y bony joint structure, by the added risks of nois es or leaks, and perhaps by a limited understandi ng of control sources. External power, control, and functional elec. t rical stimulation. External power for orthotics h as been studied almost entirely for upper-limb ne eds,12-14,24 first for flaccid paralysis and more rece ntly for quadriparesis. Bowden cablessi or hydra ulic transmission13,27 may be used occasionally to transmit power from other parts of the body. The McKibben pneumatic muscle5,53 was widely used for polio cases. Perhaps it was readily accepted b ecause it looked and acted much like a real musc le functioning in tension and because it was suffi ciently flexible to allow pronation or supination without interfering in a flexor function. Several designs25,35,55 of an electrically driven act uator have been proposed for operation of upperl imb orthoses. These may be controlled by bodyo perated switches, myoelectric signals from remai ning muscles,11 or small voluntary skin motion moving a magnet with respect to an electrical se nsor.55 Electrical stimulation of nerve and muscle tissue is rapidly growing in importance. Sensory applic ations remain largely experimental, but activatio n of muscle tissue by direct stimulation of the m otor nerve is feasible for some applications and s eems promising for others.* The lower motor ne uron must be intact for present systems. All professionals concerned should have at least elementary understanding of both electrical and physiologic principles and should recognize the i mportance of the psychosocial aspects. High sch ool physics courses teach some electrical princip les, but a far more advanced understanding is ob viously highly desirable. A group at Rancho Los Amigos Hospital has prepared a practical clinica lly oriented manuallo on history, principles, and clinical uses. Childress and Mortimerll have surv eyed the principles, application, and literature of both myoelectric control and functional electrica

l stimulation in a contribution to the medical and biologic section of the Electronics Engineers' H andbook; obviously many other sections of the Handbook are also valuable for reference. Morti mer, 41 likewise, has provided a much more det ailed review as well as additional references in a chapter in the Handbook of *References 15. 16. 26, 31~ 33, 39~ 49, 50. Physiology. Again, many other chapters provide rel evant information and references. As in the highly successful cardiac pacemaker, t he goal of functional electrical stimulation is to use small controlled pulses of external power to stimulate the appropriate muscle tissue to use m uch larger amounts of metabolic energy to perfor m useful work. The result may be enhanced by j udicious combination with an orthosis to guide a desired motion, or it may eliminate the need for an external orthosis, motor, or large battery. As with external power, much remains to be done to improve modulation of force and speed, to provi de substantial feedback, and to increase the num ber and dexterity of simultaneous coordinated ac tions. Solid and rapid progress will depend on in creased understanding of engineering as well as of biomedical and orthotic principles. CONCLUSION A moderate understanding of engineering princi ples drawn from mechanics, strength of material s, materials science, and electronics and electrica l engineering, as well as other areas of engineeri ng, will aid the entire clinic team in selecting an d wisely using materials and mechanisms to aid t he individual patient. REFERENCES
1. Alldredge, R.H., and Snow, B.M.: Lower extremity br aces. In American Academy of Orthopaedic Surgeons: Or thopaedic appliances atlas, vol. 1, Arm Arbor, Mich., 195 2, LW. Edwards, pp. 365-367, 384, 386, 388-391. 2. American Society for Testing and Materials: Annual b ook of ASTM standards (revised annually), Philadelphia, 1984, The Society. 3. Anderson, M. H.: In Sollars, R. E., et al., editors: Uppe r extremity orthoties, Springfield, ill., 1965, Charles C Th ornas, Publisher. 4. Anderson, M.H., and Bray, J.J.: The UCLA functional long leg brace, Clin. Orthop. Rel. Res. 37.98, 1964. 5. Barber, L. M., and Nickel, V. L.: Carbon dioxide powe red arm and hand devices, Am. J. Occup. Ther. 23(3):215, 1969. 6. Battelle Memorial Institute: Prevention of the failure o f metals under repeated stress, New York, 1941, John Wil ey & Sons, Inc. 7. Beer, F. P., and Johnston, E. R., Jr.: Vector mechanics for engineers: statics and dynamics, ed. 3, New York, 197 7, MeGraw-Hill Book Co. 8. Bennett, L.: Transferring load to flesh, Bull. Prosthet. Res. 10(22):133. 1974. 9. Bennett, L., Kavner, D., Lee, B. K., and Trainor, F. A.: Shear vs. pressure as causative factors in skin blood flow

occlusion, Arch. 26. Phys. Med. Rehabil. 60(7):309, 1979. 10. Benton, L.A., Baker, L.L., Bowman, B.R., and Water s, R.L.: Functional electrical stimulation-a practical clinic al guide, ed. 2, Downey, Calif., 1981, Rehabilitation Engi neering Center, Ran cho Los Amigos Hospital. 11. Childress, D., and Mortimer, J.T.: Myoelectric control and functional stimulation. Section 26, Electronics in med icine and biology. In Fink, D.G., and Christiansen, D., edi tors: Electronics engineers' handbook, ed. 2, New York, 1 982. MeGraw-Hill Book Co., pp. 26.28-33, 26.58-60. 12. Committee on Prostheties Research and Development: Orthotics research and development (report of a conferenc e), Washington, D.C., 1962, National Academy of Scienc es-National Research Council. 13. Committee on Prostheties Research and Development: The application of external power in prostheties and ortho ties (report of a conference), Publication no. 874, Washin gton, D.C., 1961, National Academy of Sciences-National Research Council. 14. Committee on Prostheties Research and Development: The control of external power in upper-extremity rehabilit ation (report of a conference), Publication no. 1352, Wash ington, D.C., 1966, National Academy of Sciences-Nation al Research Council. 15. Committee on Prosthetics Research and Development, Subcommittee on Evaluation: Clinical evaluation of the L jubIjana functional electrical peroneal brace, Report E-7, Washington, D.C., 1973, National Academy of SciencesNational Research Council. 16. Crago, P.E., Mortimer, J.T., and Peckham, P.H.: Close d-loop control of force during electrical stimulation of mu scle, I.E.E.E. Trans. Biomed. Eng. 27(6):306, 1980. 17. Donaldson, N.R., and Quigley, M.: Welding thermopl astics, Orthot. Prosthet. 31(l):51, 1977. 18. Donnell, L.H.: Stress concentrations due to elliptical d iscontinuities in plates under edge forces. In Applied mec hanics, Theodore von KArmArt anniversary volume, Pasa dena, California, 1941, California Institute of Technology, pp. 293-309. 19. Engen, T.J.: Instruction manual for fabrication and fitt ing of a below knee corrugated polypropylene orthosis, H ouston (undated), Texas Institute for Rehabilitation and R esearch. 20. England, C.L., Fannin, R.E., Skahan, JX, and Smith, H.W.: A manual of lower extremities orthotics (M.H. And erson and M. Ellison, editors), Springfield, Ill., 1972, Cha rles C Thornas, Publisher. (Prepared for the Joint Educati onal Advisory Committee, Subcommittee on Lower Extre mity Orthotics on behalf of the American Orthotic and Pr osthetic Association and the University Council on Prosth etic-Orthotic Education.) 21. illauer, C.: A new ankle-foot orthosis with a moldable carbon composite insert, Orthot. Prosthet. 35(3):13, 1981. 22. Frankel, V.H., and Burstein, A.H.: Orthopaedic biome chanicsthe application of engineering to the musculoskele tal system, Philadelphia, 1970, Lea & Febiger. 23. Frankel, V.H., Burstem, A.H., and Brooks, D.B.: Bio mechanies of internal derangement of the knee, J. Bone Jo int Surg. 53A.945, 1971. 24. Gavrilovi6, M.M., and Wilson, A.B., Jr., editors: Proc eedings of the Third International Symposium on External Control of Human Extremities, Advances in external cont rol of human extremities, Belgrade, 1970, Yugoslav Com mittee for Electronics and Automation (ETAN). 25. Grahn, E.C.: A power unit for functional hand splints, Bull. Prosthet. Res. 10(13):52, 1970. 26. Hambrecht, F.T., and Reswick, J.B., editors: Function al electrical stimulation, applications in neural prostheses, New York, 1977, Mareel Dekker, Inc. 27. Heather, A.J., and Smith, T.A.: "Helping Hand," a hyd

raulically operated mechanical hand, Orthop. Prosthet. Ap pl. J. 14(2):36, 1960. 28. Het6nyi, M., editor: Handbook of experimental stress analysis, 47. New York, 1957, John Wiley & Sons, Inc. 29. Hill, J.T., and Leonard, R: Porous plastic laminates fo r upper extremity prostheses, Artif. Limbs 7(l):17, 1963. 30. Isman, R.E., and Inman, V.T.: Anthropometric studies of the human foot and ankle, Bull. Prosthet. Res. 10(1l):9 7, 1969. 31. Jaeger, R.J., and Kndj, A.: Studies in functional electri cal stimulation for standing and forward progression. In B owman, B.R., editor, Proceedings, Sixth Annual Conferen ce on Rehabilitation Engineering, Bethesda, 1983, Rehabi litation Engineering Society of North America. 32. Kennaway, A.: On the reduction of slip of rubber crut chtips on wet pavement, snow, and ice, Bull. Prosthet. Re s. 10(14):130, 1970. 33. Kradj, A., Rajd, T., Turk, R., et al.: Gait restoration in paraplegic 51. patients: a feasibility demonstration using multichannel surface electrodes, J. Rehabil. Res. Dev. 20 (l):3, 1983. 34. Lelmeis, H.R.: New developments in lower-limb orth otics through bioengineering, Arch. Phys. Med. Rehabil. 5 3(7):303, 1972. 35. Lelmeis, H.R., and Wilson, R.G., Jr.: An electric arm orthosis, Bull. Prosthet. Res. 10(17)A, 1972. 36. Malick, M.H.: Manual on static hand splinting-new m aterials and techniques, Pittsburgh, 1970, Harmarville Re habilitation Center, pp. 30-32. 37. Matick, M.H.: Manual on dynamic hand splinting wit h thermo-plastic materials, Pittsburgh, 1978, Harmarville Rehabilitation 54. Center. 38. Malick, M. H_ and Meyer, C. M. H.: Manual on mana gement of the quadriplegic upper extremity, Pittsburgh, 1 978, Harmarville Rehabilitation Center. 39. Marsolais, E. B., and Kobetic, R.: Functional walking in paralyzed patients by means of electrical stimulation, C lin. Orthop. Rel. Res. 175:30, 1983. 40. Morris, J.M., and Blickenstaff, L.D.: Fatigue fractures -a clinical study, Springfield, Ill., 1967, Charles C Thoma s, Publisher. 41. Mortimer, JJ.: Motor prostheses. In Handbook of phys iology. Section 1, Brookhart, J.11--- and Mounteastle, V. B., section editors: The nervous system. Volume 2, Brook s, J.13-volume editor: Motor control. Part 1, Bethesda, 19 81, American Physiological Society. 42. Murphy, E.F.: Engineering considerations in the desig n of orthopaedic appliances. In American Academy of Ort hopaedic Surgeons: Orthopaedic appliances atlas, vol. 1, Arm Arbor, Mich., 1952, LW. Edwards. 43. New York University Prosthetics and Orthotics Staff.. Lower-limb orthotics with supplement, New York, 1981, New York University Post-Graduate Medical School. 44. New York University Prosthetics and Orthotics Staff.. Spinal orthotics, New York, 1983, New York University Post-Graduate Medical School. 45. Northwestern University Prosthetic-Orthotic Center: S pinal orthotics for orthotists, a course manual, Chicago (u ndated), The Cenier, Northwestern University Medical Sc hool. 46. Northwestern University Prosthetic-Orthotic Center: S pinal, lower and upper limb orthotics for physicians, surge ons, and therapists, a course manual, Chicago (undated), The Center, Northwestern University Medical School. 47. Northwestern University Prosthetic-Orthotic Center: T he Milwaukee Brace, a fabrication manual, Chicago (unda ted), The Center, Northwestern University Medical Schoo l. 48. Paul, J.P.: Forces at the human hip joint. Doctoral thes is, University of Glasgow, October 1967.

49. Peckham, P.H., Mortimer, J.T., and Marsolais, E.B.: C ontrolled prehension and release in the CS quadriplegic el icited by functional electrical stimulation of the paralyzed forearm musculature, Arm. Biomed. Eng. 8(4-6):369, 198 0. 50. Peckham, P.H., Thrope, G.B., Buckett, J.R., et al.: In Campbell, R.M., editor: Control aspects of prosthetics and orthotics. Proceedings, International Federation of Autom atic Control Symposium (Columbus, Ohio, May 1982), N ew York, 1983, Pergamon Press, Inc. 51. Pursley, R.J.: Harness patterns for upper-extremity pr osthesis. In American Academy of Orthopaedic Surgeons: Orthopaedic appliances atlas, vol. 2, Arm Arbor, Mich., 1 960, J.W. Edwards, Chapter 4. 52. Sandor, B.I.: Cyclic stress and strain, Madison, 1972, University of Wisconsin Press. 53. Schulte, H.F., Jr.: The characteristics of the McKibben artificial muscle. In Committee on Prosthetics Research a nd Development: The application of external power in pro sthetics and orthotics (report of a conference), Publication no. 874, Washington, D.C., 1961, National Academy of S ciences-National Research Council. 54. Scott, C.M., Shaw, N.A., and Amstutz, H.C.: Function al long leg brace research. Final report to the Social and R ehabilitation Service, University of California, Los Angel es, Prosthetics/Orthotics Education Program, 1971. 55. Seamone, W., and Schmeisser, G., Jr.: Status of the Jo hns Hopkins research program on upper-limb prosthesis-o rthosis power and control system, Bull. Prosthet. Res. 10 (22):237, 1974. 56. Street, D. M.: Plastic braces, In American Academy of Orthopaedic Appliances: Orthopaedic appliances atlas, vo l. 1, Arm Arbor, Mich., 1952, LW. Edwards, pp. 90-96. 57. Thorndike, A., Murphy, E. F., and Staros, A.: Enginee ring applied to orthopedic bracing, Orthop. Prosthet. App l. J. 10(4):55, 1956. 58. Timoshenko, S.: Strength of materials. 1, Princeton, N. J., 1955, D. Van Nostrand Co. (Reprint, Melbourne, Fla., 1976, Krieger.) 59. United States Manufacturing Company: Technical ma nual for vacuum forming of plastics in orthotics and prost hetics, Pasadena, Calif. (undated), The Company. 60. Weaver, H. E., and Young, J. L.: Summary reporl of S arah Mellon Scaife, Foundation Fellowship on Orthopaedi c Appliances (Nov. 1. 1949, to Aug. 1, 1951), Pittsburgh, Mellon Institute of Industrial Research, pp. 15-19. 61. Wilson, A. B_ Jr.: A material for direct forming of pro sthetic sockets, Artif. Limbs 14(l):33. 19-10. 62. Wilson, A.B.. Jr.: Vacuum forming of plastics in prost hetics and orthotics, Orthot. Prosthet. 28(102, 1974. 63. Wilson, A.B., Jr.. Condie, D., Pritham, C.11, and Still s, M.: Lower-limb orthotics-a manual, Philadelphia, 1978. Rehabilitation Engineering Center, Moss Rehabilitation H ospital. 64. Yates, G.: Method for the provision of lightweight aes thetic orthopaedic appliances, Orthopaedics 1(2052. 1968.

Newton C. McCollough III An accurate biomechanical analysis of the body

segments to be braced is fundamental to proper orthotic prescription. Until the mid-1970s there was no organized systematic approach to analyzi ng and recording basic information relating to an impaired limb or spine for the purpose of prescri bing an orthosis. More often than not, the physic ian would perform an examination, do some me ntal calculating, and then write a "prescription" b ased on rather meager knowledge of orthotic co mponents. Little thought was given to analyzing specific biomechanical defects present in the giv en limb, with the aim of translating such informa tion into an appropriate mechanical substitute. E ven when this is done, all too often the device pr escribed impairs to some degree the normal bio mechanical functions that coexist in the same li mb. For example, an orthosis prescribed for wea k knee extensors may also limit normal flexion d uring swing phase and restrict motion of the subt alar joint as well. The primary function of an orthosis is control of motion of certain body segments. These motions may be rotary, translatory, or axial. An ideal orth osis controls only those motions that are abnorm al or undesirable and permits motion where nor mal function can occur. It is apparent, then, that considerable thought should be given to each of the segments encompassed by an orthosis so the prescribed components or component types will accurately match the defects present. The basis f or orthotic prescription should be an accurate biomechanical analysis of the patient, followed b y the selection of appropriate components, and fi nally the creation of an orthotic system from the components selected. In 1968 the Committee on Prosthetics and Ortho tics of the American Academy of Orthopaedic S urgeons appointed an ad hoe committee to consi der the problem of orthotic terminology and mor e specifically charged this committee with the ta sk of developing biomechanical analysis forms t hat could be used as the basis for orthotic prescri ption. Simultaneously another ad hoe committee of the Committee on Prosthetics and Orthotics E ducation of the National Research Council-Natio nal Academy of Sciences was charged with deve loping a standard orthotic terminology and presc ription form. The two ad hoe committees worke d closely together and in 1970 published a descri ption of a combined biomechanical analysis and prescription form for the lower limb. Subsequent ly, this was refined and additional forms were de veloped for the upper limb and spine. This meth odology then became the basis for orthotic termi nology, patient analysis, and orthotic prescriptio n for the Atlas of Orthotics: Biomechanical Prin ciples and Their Application, published in 1975. In addition to simplifying and standardizing orth otic terminology, this approach aimed at reducin g orthotic prescription writing to a process of ma tching the biomechanical modes of external cont rol to the functional deficits observed. In using t his form

the physician was obligated to analyze carefully and record the functional deficits at each joint level and for each limb segment, with the aim of identifying a ppropriate orthotic controls to overcome the deficits diagramed. Orthotic components could then be selec ted to fill the needed control functions in such a ma nner as to preserve desirable remaining normal func tions. Additionally, the analysis forms were intende d to serve as a common tool or blueprint for improvi ng communication between the disciplines in difficu lt patient management problems. Finally, t was envi sioned that this form could serve a research purpose -as both a detailed documentary and a means of iden tifying orthotic solutions for which no orthotic com ponent existed. The latter in turn would stimulate fu rther research as to the design and development of n eeded orthotic components. The experience of time has demonstrated that th e biomechanical analysis-prescription forms are most useful in teaching and research. They are to o detailed and cumbersome for routine use in a c linic setting as was originally intended. Howeve r, their application to one or two patients by a res ident in training serves to teach the concept of an organized and rational approach to orthotic presc ription writing. The forms have also been helpful in precisely documenting patient status for clinic al research projects, and in this application they have improved the communication between disci plines in understanding and solving a particular problem. LOWER LIMB BIOMECHANICAL ANALYSI S SYSTEM Description of the lower-limb technic al analysis form The lower-limb technical analysis form consists of four pages of appropriate size for inclusion in the patient's hospital record. The first page (Fig. 3-1) contains spaces for pati ent data and a summary of major impairments. I n general, the impairments noted on this page ar e those that do not lend themselves to diagramm atic representation. At the bottom of the first pag e there is a legend for symbols to be used on the extremity diagrams. The second and third pages (Figs. 3-2 and 3-3) c ontain skeletal outlines of the right and left lowe r limbs respectively in the sagittal, coronal, and t ransverse planes. Overlying the major joints are shaded areas representing the normal ranges of j oint motion in each plan and contained within a circle divided into 30-degree segments. Similar s maller circles overlie the midshafts of the long b ones for diagramming angular, rotational, or tran slational deformities of the femur and tibia. Box es labeled V and H correspond to the location of each muscle group for the purpose of recording volitional muscle strength and degree of hyperto nicity respectively. Boxes labeled P are provided at each joint level for recording proprioception. The fourth page (Fig. 3-4) contains spaces for su

mmarizing the functional disability and for ident ifying the treatment objectives. The orthotic reco mmendation chart is also contained on this page along with a key for its use. Instructions for use of the lower-limb technical a nalysis form Patient data form (Fig 3-1). Most of this portio n of the lower-limb technical analysis form is sel fexplanatory. Abnormal Bone and Joint conditio ns may include such entities as osteoporosis, Pag et's disease, and coxa vara. Extremity Shortening is recorded as
Anterosuperior spine to sole of heel Anterosuperior spine to mediotibial plateau Mediotibial plateau to sole of heel

In leg-length discrepancies exceeding 1/2 inch, x -ray studies of leg length may be indicated and a n appropriate space is provided for this measure ment. Beside the heading Ligaments are checkboxes fo r indicating abnormal laxity of the major ligame nts of the knee and ankle. The headings Sensatio n, Skin, and Vascular cover considerations that may influence orthotic design and are self-expla natory. Balance can be designated either normal or impa ired, and if impaired the extent of impairment is indicated by the type of walking support used. Gait Deviations are not readily diagrammable. Major dynamic gait abnormalities should be des cribed in the spaces provided. Other Impairments should also be noted, such as upper-limb involvement or significant systemic disease. Legend and limb diagrams (Figs. 3-2 and 3-3). Two terms must first be defined: 1. Translatory motion. This is motion in whic h all points of the distal segment move in the same d irection, with the paths of all points being exactly al ike in shape and distance traversed.

TECHNICAL ANALYSIS FORM LOWER LIMB Summary of Functional Disability______________________________ Name _________________ No.________________________ _________________________________________________________ _ _________________________________________________________ Date of Onset_________________________________ _________________________________________________________ Occupation________________________ Present Lower-Limb Equipment___________________ _________________________________________________________ Diagnosis___________________________________________________________________________ _________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ Treatment Objectives: Ambulatory Non-Arnbulatory Prevent/Correct Deformity Improve Ambu MAJOR IMPAIRMENTS: Reduce Axial Load Fractu A. Skeletal Protect Joint 1. Bone and Joints: Normal Abnormal ____________________________ 2. Ligaments: Normal G Abnormal Knee: AC Ankle: MC LC ORTHOTIC RECOMMENDATION 3. Extremity Shortening: None Left Right Amount of Discrepancy: A.S.S.-Heel________ A.S.S.-MTP_______ MTP-Heel________________ 8. Sensation: Normal Abnormal 1. Anlesthesia Hypesthesia Location:______________________________________ Protective Sensation: Retained Lost 2. Pain Location:_________________________________________________________________ C. Skin: Normal Abnormal:________________________________________________________ D. Vascular: Normal Abnormal Right Left E. Balance: Normal Impaired Support:_____________________________________ F. Gait Deviations:__________________________________________________________________ __________________________________________________________________________________ REMARKS: G. Other Impairments:_______________________________________________________________ __________________________________________________________________________________ ________________________________ _______________________ --------------------------------------------------------LEGEND-------------------------------------------------------Signature Date Direction of Translatory Volitional Force (V) Motion N Normal N = Normal _________________________________________________________ G Good 1 = Impaired KEY: Use the following symbols to indicate desired control of designat F Fair A = Absent F = FREE - Free motion. Abnormal Degree of P Poor A = ASSIST - Application of an external force for the purpose of increa 60. Rotary Motion T Trace D = Local Distension or n. Z Zero Enlargement R = RESIST - Application of an external force for the purpose of decre Fixed Position STOP - Inclusion of a static unit to deter an undesired motion in one di Hypertonic Muscle (H) U v = Variable - A unit that can be adjusted without making a structural c 1 CM. N = Normal Pseudarthrosis H = HOLD - Elimination of all motion in prescribed plane (verify posit n L = LOCK - Device includes an optional lock. M = Mild Mo = Moderate Fracture S = Severe Absence of Segment

2. Rotary motion. This is motion of a distal se gment in which one point in the segment or in its (i maginary) extension always remains fixed. The symbols described in the legend are used in conjunction with the right-limb and left-limb dia grams according to the following rules:

1. Rules pertaining to recording moti on a. Diagramming motion. The degrees of rotar y motion or centimeters of translatory motion are to be obtained from passive manipulation and are to re flect passive, not active, motion at the site being exa mined. In the lower limb, joints are to be observed d uring weight bearing, and if the degree of joint excu rsion is greater under conditions of loading than by passive manipulation, this figure is diagrammed rath er than the smaller figure (e.g., recurvatum of the kn ee). b. Translatory motion. Linear arrows horizontally pl aced below the circle indicate the presence of (abnor mal) translatory motion at one or more of the six de signated levels of the lower limb listed on the left si de of the form. The head of the arrow always points in the direction of displacement of the distal segmen t relative to the proximal segment. Linear arrows ve rtically placed on the right side of the circle indicate (abnormal) translatory motion along the vertical axi s at the site indicated. c. Rotary motion. Normal ranges of rotary motion a bout joints are preshaded on the diagram. Abnormal rotary motion, either limited or excessive, is shown by doubleheaded arrows placed outside and concent ric to the circle, indicating the extent of available m otion present in the affected joint. In certain instanc es it may be more meaningful to use two double-hea ded arrows to describe the range of motion to either side of the neutral joint axis rather than a single arro w that describes the total range of motion present. If one head of an arrow fails to reach the preshaded m argin, limitation of joint motion is designated. Conv ersely, if one head of an arrow projects beyond the p reshaded margin, excess motion is designated. Num bers in degrees are placed adjacent to the arrows to i ndicate the arc described. In addition, radial lines dr awn from the center of the circle and passing throug h its perimeter at the tips of the double-headed arro w are used for more graphic representation of the ar c of available motion. At sites where rotary motion does not normally occur (e.g., the knee joint in the c oronal plane), the presence of abnormal rotary moti on is similarly designated by a double-headed arrow with adjacent numerical value in degrees. d. Fixed position. Double radial arrows indica te a fixed joint position and describe in degrees the deviation from the neutral joint position in translator y sense, and the extent of abnormal translation is in dicated in centimeters adjacent to the arrow (e.g., su bluxated tibia in the knee of a hemophiliac). 2. Rules pertaining to muscle a. Volitional force. Volitional force of muscle group s (e.g., hip flexors) is determined by conventional m eans on the examining table. The legend symbol cor responding to muscle strength is recorded in the box labeled V (for volitional) adjacent to the skeletal out line at the proper location for each muscle group. T he letter grades correspond to the standard muscle g rading system used in poliomyelitis. A cheek mark i s used if muscle strength is normal. b. Hypertonicity. Hypertonicity is fu


identified in the legend as H. The symbol for muscle group tone (e.g., Mo ' ) is place d adjacent to the skeletal outline in the box labeled H at the proper location for each muscle group. Hypertonic muscle esti mates are made with the patient in the functional position for the lower limb (i.e., during standing and walking). The letter grades for hypertonic muscle are as follows: N normal muscle tone M mild degree of hypertonicity, functionally i nsignificant Mo moderate degree of hypertonicity, sufficient for useful holding quality, or with some functional valu e S severe hypertonicity, obstructive in terms of funct ion Muscle groups in a patient with spastic paralysis may also be graded according to volitional force (e.g., dorsiflexors of the foot in a hemiplegic per son). 3. Rules pertaining to proprioception a. A box labeled P is provided at each of the major joint levels. The appropriate symbol for propr ioceptive loss is placed in the box according to the l egend. 4. Rules pertaining to fracture or bone deformity. a. All translatory or rotary motions at the frac ture on the shaft of a long bone are diagrammed on t he circle located at the midshaft of each bone. The a ctual fracture site is indicated by the fracture symbo l. All bony deformities (e.g., valgus angulation of th e shaft) are likewise diagrammed on the circle locat ed at the center of the shaft, regardless of the positio n of the angular deformity. The location of the defor mity is designated by circling the appropriate level of the left-hand side of the chart. Summary of functional disabilities (Fig. 3-4). This is intended to be a concise analysis of the fa ctors that are significant in producing functional impairment and for which orthotic control is des irable. Treatment objectives (Fig. 3-4). The objectives are identified by checking the appropriate boxes. There may frequently be more than one objectiv e treatment. Orthotic recommendation (Fig. 34). The level of orthotic application is selected on the basis of the information obtained. A full lower-limb orth osis to include the hip is identified in the chart as an HKAO (hip-knee-ankle orthosis) whereas an a ppliance designed to control only the ankle-foot complex would be designated as AFO. For each joint to be encompassed or controlled b y the device, the type of control in each direction of movement is inserted in the blanks provided, abbreviated according to the key at the bottom of the page. Thus the types of control to be provide d, and not the specific components to be used, fo rm the basis of the orthotic recommendation. Un

der the section concerning remarks more exactin g recommendations as to components or special considerations in fabrication can be recorded. Illustrative cases Case 1 (Figs. 3-5 to 3-7). This 22-year-old male was seen for residual paralysis of the left lower l imb because of poliomyelitis. Fig. 3-5 provides basic background information regarding this patient. His present orthosis was o f the conventional above-knee type with drop-rin g knee locks and a 90-degree plantar stop at the ankle. He had undergone a triple arthrodesis of t he left foot. The medial collateral ligament were lax, and there was 13/4 inch shortening of the lef t lower limb. Pain was present about the left ankl e, and his gait was characterized by a gluteus me dius limp and eircumduction of the limb. Diagrammatic analysis of the limb (Fig. 3-6) giv es a clear picture of the voluntary strength of all four muscle groups indicated by letter grade. In t he sagittal plane there was loss of 30 degrees of hip extension with 20 degrees of hyperextension of the knee, plus limitation of dorsiflexion of the ankle to the neutral position. In the coronal plan e a 15-degree valgus excursion of the knee was present, as well as approximately 10 degrees of abnormal inversion and eversion of the ankle joi nt secondary to an old triple arthrodesis of the fo ot, indicated by the fixed position of the subtalar joint. In the transverse plane there was 20 degree s of external tibial torsion. Proprioception was, o f course, normal throughout the limb. The summary of this patient's functional disabili ty (Fig. 3-7) and the objectives of treatment are s elf-explanatory. The orthotic recommendation (Fig. 3-7) indicated that it was desirable to allow free knee flexion and stop hyperextension of the knee. At t he ankle the combination of a dorsiflexion stop a nd resistance to plantar flexion was recommende d to achieve knee stability by creating an extensi on moment at this joint during stance phase. It w as also considered desirable to stop inversion an d eversion forces (in reality occuring at the ankle joint), since this was a source of pain. In the section concerning remarks it is suggested that these orthotic requirements could be met by the "TCLA functional long leg orthosis" in comb ination with a "UCB" type of shoe insert. Case 2 (Figs. 3-8 to 3-10). This 63-year-old mal e was seen for residual paralysis of the lower lim b secondary to cerebral thrombosis. Fig. 3-8 illustrates the basic background informa tion and the areas of major impairment in this pa tient. His present orthotic equipment consisted o f a conventional below-knee orthosis with a 90-d egree plantar stop. Some hypesthesia existed on the left side of the body and his balance was imp aired to the extent that he had to use a cane in a mbulating. His gait was characterized by inversi on and dropfoot during swing phase, and hypere xtension of the knee at midstance. Diagrammatic analysis of the limb (Fig. 3-9) giv

es a clear picture of the volitional strength of the major muscle groups. In addition, it can be seen that a mild degree of spasticity was present in th e adductors of the hip and the plantar flexors and invertors of the foot and ankle. Proprioception w as impaired distally, but normal at the knee and hip joints. In the sagittal plane, a 25-degree excu rsion of the knee and limitation of dorsiflexion o f the ankle to the neutral position existed. The summary of this patient's functional disabili ty and the objectives of treatment are self-explan atory (Fig. 3-10). The orthotic recommendation (Fig. 3-10) called for free Text continued on p. 48. dorsiflexion and a plantar-flexion stop 10 degrees a bove neutral to aid in preventing hyperextension for ces at the knee during stance phase. Also resistance to inversion and free eversion at the subtalar joint w ere indicated, along with elimination of all flexion-e xtension motion in the tarsal and midtarsal joints. T he purpose of this was to effect a right foot-lever sy stem for transmitting a flexion moment to the knee t hrough the calf band at heel strike. In the section concerning remarks, specific sugg estions are made with regard to the components of this system. UPPER LIMB BIOMECHANICAL ANALYSIS SYSTEM As in the lower limb, the primary function of an orthosis is to control motion of body segments. Additionally, in the upper limb, an orthosis may also provide motion through the use of external power sources. An ideal orthosis controls or pro vides only those motions that are abnormal or ab sent and permits unrestricted motion in areas wh ere normal function remains. It thus becomes ob vious that considerable thought should be given t o each level and segment of the limb encompass ed by an orthosis so the prescribed components, or component types, will accurately match the d efects present. The basis for orthotic prescription should therefore be an accurate biomechanical a nalysis of the patient, followed by the selection o f appropriate components, and finally the creatio n of an orthotic system from the components sel ected. Description of the upper-limb technical analysis f orm The upper-limb technical analysis form consists of four pages of appropriate size for inclusion in the patient's hospital record. Separate forms are provided for the right and left upper limbs. The first page (Fig. 3-11) contains spaces for pat ient data and a summary of major impairments. I n general, the impairments noted on this page ar e those that do not lend themselves to diagramm atic representation. At the bottom of the first pag e there is a legend for symbols to be used on the limb diagrams. The second page (Fig. 3-12) contains skeletal ou

tlines of the upper limb in the sagittal, coronal, a nd transverse planes. Overlying the major joints are shaded areas representing the normal ranges of joint motion in each plane and contained with in a circle divided into 30-degree segments. Simi lar smaller circles overlie the midshafts of the lo ng bones for diagramming angular, rotational, or translational deformities of the humerus and fore arm. Boxes labeled V and H are provided to corr espond to the location of each muscle group for t he purpose of recording volitional muscle streng th and degree of hypertonicity, respectively. Box es labeled P are provided at each joint level for t he purpose of recording proprioception. A sensat ion diagram for the upper limb exclusive of the h and is provided in the insert. The third page (Fig. 3-13) is to be used for the bi omechanical analysis of the hand. At the top of t he page, dorsal and volar outlines of the hand ar e for recording sensation according to the symbo ls in the legend, including proprioception and ste reognosis. Also spaces are provided for recordin g volitional strength and hypertonicity of individ ual muscles, and angular deformities of the meta carpophalangeal joints. Vertical scales are provi ded for linear recording of the opening and closi ng capacity of each finger and the oppositional c apacity of each finger to the thumb. A horizontal scale is used to describe the opening and closing capacity of the thumb. A sagittal diagram is prov ided for recording the goniometric measurement s of each digit and thumb. Finally, there is space for recording the power of prehension. The fourth page (Fig. 3-14) contains spaces for s ummarizing the functional disability and identify ing treatment objectives. The orthotic recommen dation chart is also contained on this page along with a key for its use. Instructions for use of the upper-limb analysis fo rm First page. Page one (Fig. 3-11) is for recording general patient information and data that cannot be readily diagrammed on subsequent pages. It a lso legend) to be used on pages 2 and 3 (Figs. 312 and 3-13). Most of the items on the front pag e are self-explanatory. If the opposite limb is als o impaired, space is provided for a brief descript ion of the handicap. If coordination is impaired, function is recorded as being normal. compromis ed, or prevented. Second page. Page two (Fig. 3-12) presents outl ines of the upper limb in the sagittal, coronal, an d transverse planes. Overlying the major joints a re circles divided into 30-degree segments. The s haded area within each circle represents the nor mal range of motion present in the unimpaired li mb. Recording motion. The degree of rotary or tran slatory motion is obtained from passive manipul ation of the joint being examined. Translatory motion. Linear arrows placed adja cent to the circle indicate the direction of abnor mal translatory motion of a joint (subluxation or

dislocation). The head of the arrow always point s in the direction of displacement of the distal se gment relative to the proximal. A number grade (1, 2, or 3) is placed next to the arrow to indicate the severity of displacement, as indicated in the l egend. Grade 1 = Subluxation Grade 2 = Dislocation, reducible Grade 3 = Dislocation, irreducible Rotary motion. The are of available motion is d escribed by two radial lines drawn from the cent er of the circle to its perimeter. A double-headed arro w, as illustrated in the legend, is drawn outside and concentric to the circle between the radial lines, and the number of degrees of motion within this are is re corded adjacent to the arrow. In certain instances, it may be desirable to use two doubleheaded arrows to describe the joint motion to either side of the neutral joint axis rather than a single arrow to describe the t otal range of motion present. NOTE: If it is desired to diagram active as well as passive motions, a color code can be used to d ifferentiate the two. Fixed positions or ankylosis of a joint are indicated by a double arrow from t he center of the circle to its perimeter, with the p osition of the joint noted in degrees adjacent to t he head of the arrow, as indicated in the key (or legend). Scapulothoracic motion. In the coronal plane, a ctive elevation of the scapula is indicated as bein g normal (N), impaired (I), or absent (A). In the t ransverse plane, abduction and adduction of the scapula are recorded in centimeters from the vert ebral border to the spinous process of the thoraci c vertebrae along the double-headed arrow. Recording muscle power and tone. Two aspect s of muscle function are recorded: Volitional power. This is determined by convent ional muscle testing, and the letter grade as defin ed in the legend (Fig. 3-11) for each muscle grou p (such as flexors and internal rotators) is placed in the box labeled V in the appropriate area for t hat muscle group (Fig. 3-12). Hypertonicity. The hypertonicity of each muscle group is graded as follows, and the letter grade p laced in the appropriate box for the muscle grou p labeled H: N normal muscle tone M mild hypertonicity. with minimal impairme nt of function Mo moderate hypertonicity, which compromise s but is compatible with function S severe hypertonicity, which is obstructive t o function Recording sensation. Two qualities of sensatio n are noted:

Proprioception. This is recorded on the right of t he page at the level of each major joint in the bo x labeled P, by use of the key described in the le gend. Tactile sensation. This quality of the upper lim b, exclusive of the hand, is described on the sens ation diagram (inset) according to the key in the legend. Hand diagram Recording motion Goniometric method. The skeletal outline of a fi nger and thumb in the sagittal plane is used to re cord degrees of motion in the small joints of the digits. Concentric arcs about each finger joint pl ot the range of motion for index, middle, ring, an d little fingers. Hatch marks along the outer are (index finger) are at 30-degree intervals. These r anges may be plotted by means of a dot or mark at the extremes of motion connected by a heavy l ine or shading. A color code may be used to disti nguish active from passive motion. The normal a rcs of motion for each joint (numbered in degree s) are defined by the shading between the heavy radial lines. The joints of the thumb are similarly diagrammed. The angle of the web space of the t humb (in the plane of the palm) is recorded on th e dorsal sketch of the hand. Radial or ulnar devia tion of the fingers is recorded by means of radial arrows numbered in degrees in the circles over t he metacarpophalangeal joints. Linear method. Linear measurements may also be used to describe the opening and closing capa city of the hand. Fingers. The opening capacity for each finger is described by measuring the distance in centimet ers from the tip of the extended finger to the dist al flexion crease of the wrist and marking the ver tical scale for each finger. Normals are shaded o n the respective columns for each finger. A mark is made on the left side of the column for active motion and on the right side for passive motion. The closing capacity of each finger is described i n much the same way. The distance in centimete rs from the tip of the finger to the midpalmar cre ase is measured and recorded. The resulting inter vals between full opening and full closing for ea ch finger give a diagrammatic picture of finger e xcursion. Thumb. The opposing capacity of the thumb is a ssessed by measuring the maximum vertical dist ance in centimeters from the tip of the thumb to t he midpalm as the thumb is opposed to each fing er and recording on the vertical scale. Active me asurements are recorded on the right side of the column for each finger, and passive measuremen ts op the left side. To assess the opening and clos ing of the thumb in extension-abduction versus f lexion-adduction requires measuring the distanc e from the tip of the thumb to the head of the fift h metacarpal in full extension - abduction and fu ll flexion-adduction and then marking both meas

urements on the horizontal scale. Recording muscle power and tone. Three aspe cts of muscle functioning are recorded: Volitional power. This is determined by convent ional means, and the letter grade for each muscle (see legend) is recorded in the box correspondin g to the insertion of each tendon. Interosseous str ength for abduction-adduction and metacarpoph alangeal flexion is recorded on the palmar diagra m; for proximal interphalangeal joint extension, it is recorded on the dorsal diagram. Hyperionicity. The hypertonicity of the muscles to each digit is recorded in the box marked H at t he tip of each finger for both flexors (palmar dia gram) and extensors (dorsal diagram) based on t he code in the legend. If muscle tone is normal. a cheek mark is made. Functional motor power. This assessment of th e hand is measured by use of conventional pinch meters and grip dynamometers, and the values ar e recorded for power grip, palmar prehension, an d lateral prehension. Recording sensation. Three aspects of sensatio n also are noted: Proprioception. This is recorded in the box labe led P at the tip of each digit based on the code in the legend. Stereognosis. This is recorded, in the space provided, as normal (N), impaired (I), or a bsent (A). Tactile sensation. This is diagrammed as an ove rlay on the palmar and dorsal hand diagrams acc ording to the key in the legend. Summary and recommendations (Fig. 3-14) From the data recorded, a concise summary of th e functional disability is recorded in the spaces p rovided and treatment objectives are identified. The orthotic recommendation (or prescription) c hart is then completed according to the key at th e bottom of the page. If the entire upper limb is t o be included in the device prescribed (shoulderelbow-wrist-hand orthosis, SEWHO), the decisio n must be made as to the requirements for the co mponents at each joint level and for each move ment (flexion, extension, adduction, abduction, r otation, and axial load). Motions that do not appl y to specific joints are blocked out. Illustrative cases
Case 1 (Figs. 3-15 to 3-18). A 38-year-old female was seen for upper-limb involvement secondary to rheuma toid arthritis. She was ambulatory with the aid of a kn ee-ankle-foot orthosis for genu valgum and complaine d of pain in both wrists. Diagrammatic analysis of the right upper limb (Fig. 316) exclusive of the hand gave a clear picture of the v oluntary muscle strength of all muscle groups and the range of motion present in all major joints. In the sagit tal plane there was absence of the last 60 degrees of fo rward flexion of the shoulder, as well as inability to ac hieve the last 30 degrees of shoulder extension. A 45degree flexion contracture of the elbow and a 20degre

e flexion contracture of the wrist were present. In the coronal plane there was limitation of the last 30 degre es of shoulder adduction and the wrist was in uinar de viation with 10 degrees of excessive deviation possibl e. Loss of external rotation at the shoulder and limitati on of pronation and supination of the wrist were noted in the transverse plane. Diagrammatic analysis of the hand (Fig. 3-17) showe d the volitional strength of each muscle at its insertion on dorsal and palmar sketches of the hand. Also evide nt were the ulnar deviation deformities of the digits at the metacarpophalangeal joints, along with contractur e of the web-space angle to 35 degrees. Excursion of t he joints of each finger was recorded on both linear an d goniometric diagrams. The flexion contracture of th e distal interphalangeal joints and the extension contra ctures of the proximal interphalangeal joints of the ind ex and middle fingers indicated typical swan-neck def ormities of these digits. The metacarpophalangeal join ts were dislocated and irreducible, as indicated by the arrow and the adjacent numeral 3. All modes of prehe nsion were greatly reduced in power, and there was co nsiderable limitation of the opening capacity of the th umb in extension-abduction. Fig. 3-18 indicates that the primary functional disabili ty was weakness of grasp secondary to progressive de formity and pain and that the objective of orthotic trea tment was to prevent and correct the deformity and rel ieve the pain. The orthotic recommendation was to ho ld the wrist statically in 20 degrees of flexion and 20 d egrees of ulnar deviation, to assist metacarpophalange al extension and resist metacarpophalangeal flexion as well as assist radial deviation of the fingers and resist ulnar deviation. It was also desirable to assist the carp ometacarpal joint of the thumb in abduction and resist adduction of this joint. A method of achieving these objectives is to use a pad ded thermoplastic splint to hold the wrist in the prescr ibed position with the addition of an outrigger for dyn amic finger extension and thumb abduction. Case 2 (Figs. 3-19 to 3-22). A 22-year-old male was s een for evaluation of upper-limb disability secondary t o spinal cord injury at the C5-6 level with resulting qu adriplegia. Basic background information for this patient appears in Fig. 3-19. In Fig. 3-20 the volitional strength for ea ch muscle group in the upper limb, exclusive of the ha nd, is provided as well as the information that there w as no passive limitation of joint movement in the shou lder, elbow, or wrist. The hand diagram (Fig. 3-21) is shaded according to t he code in the legend to indicate anesthesia in the area of the C7 and C8 dermatomes and hypesthesia in the C6 dermatome. No volitional motor power was presen t in the intrinsic or extrinsic muscles of the hand. Prop rioception and stereognosis were absent. Goniometric analysis of the fingers showed a 20-degree flexion co ntracture of the proximal and distal interphalangeal joi nts of all fingers. The linear measurement chart showe d reduced passive opening capacity of the fingers and reduced passive excursion of the thumb into extension -abduction. Fig. 3-22 indicates that the primary functional disabili ty was inability to grasp. The orthotic recommendatio n was for a wrist-hand orthosis with free flexion and e xtension of the wrist in 10 degrees of radial deviation, free metacarpophalangeal flexion and extension of dig its 2 and 3, immobilization of the proximal interphala ngeal joints of digits 2 and 3 at 45 degrees of flexion,

and immobilization of the distal interphalangeal joints at 15 degrees of flexion. With regard to the thumb, the carpometacarpal joint was to be immobilized at 45 de grees of abduction and the metacarpophalangeal joint and the interphalangeal joint were to be immobilized at 10 degrees of flexion. The orthosis was to he driven by the wrist extensors, providing opposition of the sec ond and third fingers to the thumb. Summary

The basis for any rational orthotic prescription m ust be a systematic functional appraisal of the im paired limb or body segments. The diagrammati c approach to biomechanical analysis of the upper lim b presented here serves to make a better identificatio n of the functional deficits present and forms the bas is for appropriate selection of orthotic components. It also identifies instances for which adequate comp onents are not available to perform the required task s, thus denoting areas for further research. In additio n to serving as a means for developing a logical app roach to orthotic prescription, such a technical analy sis provides an improved means of communication between the physician and the orthotist. Although th e analysis form itself need not be applied to all patie nts requiring an orthosis, the concept of a biomecha nical approach of this nature is essential to the devel opment of a sound orthotic prescription. BIOMECHANICAL ANALYSIS SYSTEM FOR THE SPINE Of the three major areas of the body under consi deration for orthotic application, the spine is per haps the most difficult to describe accurately in a biomechanical analysis. The upper and lower li mbs, by virtue of the accessibility of their articul ations and motors to physical examination, lend t hemselves well to diagrammatic representation o n a technical analysis form. The deeply seated jo ints of the spine, with their gross and less well-d efined motor control units, present a difficult pro blem in examination, diagnosis, and identificatio n of biomechanical deficits. Of course, orthotic p rescription for the spine can reach no greater lev el of sophistication than that permitted by the ac curacy of identifying biomechanical abnormaliti es. With these considerations in mind, we still co nsider some method of tabulation or diagrammat ic representation of the biomechanical status of t he spine to be highly desirable as a basis for proc eeding with a rational orthotic prescription. The method described, utilizing the spinal technical a nalysis form, provides the examiner with a syste matic and illustrative means of recording pertine nt data upon which the orthotic prescription can be based. Description of the spinal technical analysis form The spinal technical analysis form consists of fo ur pages suitable for inclusion in the patient's ho spital record. The first page (Fig. 3-23) contains spaces for pat

ient data and a summary of major impairments. I n general, the impairments noted do not lend the mselves well to diagrammatic representation. The second page (Fig. 3-24) contains a legend fo r symbols to be used in conjunction with the skel etal outline to complete the biomechanical analy sis. The third page (Fig. 3-25) contains a skeletal out line of the spinal column and pelvis in the coron al, sagittal, and transverse planes. The fourth page (Fig. 3-26) provides a space for summarizing the functional disability and identif ying treatment objectives. The orthotic recomme ndation or prescription form is also included on t his page for the purpose of indicating the type of motion control desirable at each level of the spin e in each plane. Instructions for use of the spinal technical analys is form Major impairments (Fig. 3-23). Most of this po rtion of the form is self-explanatory. In general, observations to be recorded here do not lend the mselves to diagrammatic illustration on the follo wing page. These include structural abnormalitie s (e.g., the character of bone and disc space invol vement), sensory abnormalities, upper and lower limb deficits that may influence spinal alignment and orthotic prescription, balance impairment, a nd any associated impairments that may have be aring upon selection of treatment. Spinal diagram and key (Figs. 3-24 and 3-25). On each side of the spinal column in the coronal, sagittal, and transverse planes small rectangular boxes with appended arrows are located at the ce rvical, thoracic, and lumbar levels for the purpos es of indicating range of motion of the spinal seg ments. Range of motion is recorded within these boxes to indicate the estimated percent of norma l motion retained at each level and in each direct ion. In fixed rotational deformities (e.g., scoliosi s) the estimated degree of rotation at each level i s recorded in the appropriate box using the radiol ogic method described by Nash and Moe. 2 Also located adjacent to the spinal column are small b oxes labeled V and H for muscle strength of the l ateral flexors and extensors and forward flexors of the spine. Since these muscle groups are not r eadily distinguishable in their effects on the thor acic and lumbar spine separately, thoracolumbar motors are graded together. The quadratus lumb orum (Q) and iliopsoas (I) are graded separately on each side of the lumbar spine in the coronal p lane. Active volitional strength of these muscles is recorded in the box labeled V and hypertonicit y, if present, is recorded in the box labeled H at each level according to the scale in the legend. Curvature of the spine in the coronal or sagittal plane is indicated by transverse lines drawn thro ugh the spinal column at the upper and lower li mits of the curve. The direction of the curve is i

ndicated by a bracket on the convex side extend ing between the end vertebrae. The apical verte bra is identified at the center of the bracket, as a re the magnitude of the curve in degrees and wh ether it is a primary or secondary curve. Pelvic tilt is indicated by directional arrows ove rlying the outline of the pelvis. Symbols for arthrodesis, fracture, arthritis, and s egmental instability contained in the legend are to be used in an overlay fashion on the diagram to indicate specific areas of involvement. Summary of functional disabilities (Fig. 3-2 6). This is intended to be a concise analysis of t he factors that are significant in producing funct ional impairment and for which orthotic control is desirable. Treatment objectives (Fig. 3-26). The objectiv es of orthotic treatment are identified by checki ng the appropriate boxes. There frequently may be more than one objective of treatment. Orthotic recommendation (Fig. 3-26). The lev el of orthotic application is selected on the basis of the information obtained. A full spinal orthos is to include the cervical, thoracic, and lumbar s egments and sacrum is identified in the chart as a CTLSO whereas a device to control only the l umbar and sacral spine would be an LSO. For each segment of the spine to be encompasse d or controlled by the orthosis, the type of contr ol in each direction of motion in each plane is in serted in the blanks provided, abbreviated accor ding to the key at the bottom of the page. Thus t he types of control to he provided, and not the s pecific components to be used, form the basis of the orthotic recommendation. Under the section concerning remarks more exacting recommenda tions as to components or special considerations in fabrication can be recorded. Case illustrations
Case 1 (Figs. 3-27 to 3-29). This 58-year-old female was seen for low back pain secondary to osteoporosi s, compression fractures, and ostcoarthritis. Fig. 3-27 provides the basic background information r egarding this patient's disability. She had a compressi on fractures of the eleventh and eighth thoracic verteb rae as well as narrowing of the L4-5 and L5-S1 inters paces. Pseudospondy-lolisthesis was present at the L4 -5 interval. The pain was primarily in the low dorsal a nd lumbar areas, radiating into the right hip and poster ior thigh. Diagrammatic analysis of the spine (Fig. 3-28) gives a more detailed picture of the abnormalities present. In t he coronal plane there was a limitation of lateral flexi on in the thoracic area to about 20% of normal, and in the lumbar area 40% of normal lateral flexion was ret ained to each side. Muscle strength was normal throug hout the spine, and degenerative arthritis involved L4, L5, and St. In the sagittal plane, although full range of motion was retained in the cervical spine, there was es sentially no remaining motion in flexion or extension i n the thoracic area. Only 20% of normal flexion and e xtension remained in the lumbar spine. Compression f ractures were noted at the level of T8 and T11, and a kyphotic curve extended from the first to the eleventh

thoracic vertebra, measuring 65 degrees. An area of se gmental instability secondary to pseudospondy-lolisth esis was present between L4 and L5, and once again d egenerative arthritis of L4, L5, and S1 is diagrammed. In the transverse plane normal cervical rotation was re tained. whereas rotation in the thoracic area was aboli shed completely. and 50% of normal rotation remaine d to each side in the lumbar segment. In Fig. 3-29 it is noted that the functional disability co nsisted primarily of limited mobility, secondary to pai n that was, in turn, secondary to compression fracture s, osteoporosis, osteoarthritis, and segmental instabilit y. The objective of orthotic treatment was motion cont rol to reduce or eliminate the existing pain. The orthot ic recommendation called for stopping motion of the s pine in all three planes at the thoracic, lumbar, and lu mbosacral levels. In addition, reduction of axial load was considered desirable. The specific orthosis recom mended to accomplish these biomechanical objectives was a thoracolumbosacral orthosis JLSO) providing b oth anteroposterior and mediolateral control, utilizing an abdominal corset. Case 2 (Figs. 3-30 to 3-32). This 13-year-old female was seen with the diagnosis of idiopathic scoliosis. Fig. 3-30 indicates the presence of early Scheuermar m's disease and absence of any other major impairmen ts. Technical analysis of the spine (Figs. 3-30 and 3-31) d etails the abnormalities present. In the coronal plane a primary curve extended from T4 to T10, convex to the right, with the apex at T7 measuring 40 degrees. Ther e was also a lumbar curve, also primary, extending fro m TI1 to L4, convex to the left, with the apex at 1,2 m easuring 34 degrees. Right lateral bending was limited to 80% of normal in the thoracic area, and left lateral bending to 80% of normal in the lumbar area. Muscle strength was recorded as normal throughout. In the sa gittal plane a full range of the cervical, thoracic, and l umbar spine was present in flexion and extension, and the flexors and extensors of the spine were of normal strength. In the transverse plane there was a 50-degree fixed rotational deformity to the right in the thoracic a rea and a 50-degree fixed rotational deformity to the l eft in the lumbar area. In Fig. 3-32 the functional disability is considered to b e progressive deformity secondary to idiopathic scolio sis. The orthotic objectives of treatment were spinal al ignment, motion control, and axial unloading. The ort hotic recommendation chart indicates that the cervica l, thoracic, lumbar, and lumbosacral segments of the s pine were to be controlled with an orthotic device. Th e types of motion control desirable at each level of the spine in each plane of movement are recorded by sym bols in the chart. The orthotic device recommended to achieve these biomechanical controls was a Milwauke e brace utilizing a throat mold, a polypropylene pelvic girdle, a ri ght thoracic pad at the level of T8, and a left lumbar pad a t the level of T4.

n or deformity or both. Diagrammatic representa tion of these abnormalities permits one to select better the types of motion control that are most d esirable for the individual patient. The orthotic d evice prescribed thus represents a synthesis of th e desired controls at each level of the spine in ea ch plane of movement. REFERENCES 1. McCollough, N.C., Ill, Fryer, C.M., and Gl ancv, L: A new approach to patient analysis for orth otic prescription, Artil. Lirribs 14:68. 1970. 2. Nash. C.L.. and Moe, J.H.: A stud y of vertebral rotation, J. Bone Joint Surg. SIA:223, 1969.

Jacquelin Perry Walking depends on the repeated performance b y the lower limbs of a sequence of motions that s imultaneously advances the body along the desir ed line of progression while also maintaining a st able weightbearing posture. Effectiveness depen ds on free joint mobility and muscle action that i s selective in both timing and intensity. Normal f unction also is optimally conservative of physiol ogic energy. Pathologic conditions alter the mod e and efficiency of walking. The loss of some act ions necessitates substitution of others if forward progression and stance stability are to be preserv ed. Through a detailed knowledge of normal fun ction and the types of gait errors that the various pathologic conditions can introduce, the clinicia n becomes able to define the significant deficits and plan appropriate corrective measures. NORMAL GAIT Gait cycle Each sequence of limb action (called a gait cycl e) involves a period of weightbearing (stance) an d an interval of self-advancement (swing) (Fig. 4 -1). During the normal gait cycle approximately 60% of the time is spent in stance and 40% in sw ing.16 The exact duration of these intervals varies with the walking speed. There also are minor dif ferences among individuals. The reciprocal action of the two limbs is timed to trade their weightbearing responsibility during a period of double stance (i.e., when both feet are in c ontact with the ground) and usually involves the ini tial and terminal 10% intervals of stance. The mi ddle 40% is a period of single stance (single-limb su pport). During this time the opposite limb is in swin

Summary The initial step in any orthotic prescription for th e spine must be the identification of abnormal bi omechanical factors for which orthotic control is desirable. The factors to be studied include stren gth, motion, alignment, and intrinsic disease pro cesses, as they relate to the clinical picture of pai

g. Functional elements The three components of walking-progression, st anding stability, and energy conservation-involv e distinct functional patterns. These need to be u nderstood for an appropriate interpretation of so me of the limitations displayed by patients. Alth ough for this description they will be separated, during walking all three action patterns are intert wined throughout each stride. Progression. There are forces: 1. The primary one is forward fall of the body weight (Fig. 4-2). This begins in single stance as the ankle dorsiflexes beyond neutral and accelerates wit h heel rise. 2. The second, which is generated by the cont ralateral swinging limb (Fig. 4-3), starts with the on set of single limb support. This action is particularly important before the body is aligned for an effective forward fall. The momentum generated by these two actions i s optimally preserved at the onset of the next sta nce phase by floor contact with the heel. As the f oot drops toward the floor, the pretibial muscles draw the tibia forward (Fig. 4-4). At the same ti me the quadriceps ties the femur to the leg so the thigh also advances (though at a slightly slower r ate). Thus, throughout the stance period the heel, ankle, and forefoot serially serve as a rocker that allows the body to advance over the supporting f oot (Fig. 4-5). For this to occur the foot must be appropriately positioned by the end of swing and controlled as weight is applied. Then, during the support phases there must be adequate passive m obility at the ankle. This necessitates both a free joint range and ability of the calf muscles to yiel d as they provide tibial stability. Standing stability. Balance is challenged by tw o factors. The body is top-heavy, and walking co ntinually alters segment alignment. During walki ng the body divides itself into two functional uni ts-passenger and locomotor. The head, arms, and trunk are the passenger unit because they are carried rather than directly cont ributing to the act of walking. Muscle action wit hin the neck and trunk serves only to maintain n eutral vertebral alignment. There is minimal post ural change occurring during normal gait. Arm s wing is primarily a passive reaction to the wome ntum generated. The small amount of active control h as not proved essential, as evidenced by the case wit h which one carries packages. Also, experimental re straint of arm swing registers no change in the energ y cost of walking.'9 The composite mass center of t hese segments is just anterior to the tenth thoracic v ertebra and thus lies well above the hip, joints. This long lever (33 cm in an average adult ) makes balan ce of the passenger unit very sensitive to alignment changes of the supporting limbs. The locomotor unit consists of two limbs joined

by the intervening pelvis. This makes the pelvis an element of both the passenger and the locomo tor units with two highly mobile junction sites, t he lumbar spine and hip joints. Theoretically, weightbearing stability of the limb is maximal when its three components (thigh, le g, and foot) are vertically aligned so one is direct ly over the center of the other. If these segments were square blocks, there would be a broad shou lder to allow considerable tilting before balance was lost. Instead, the femur and tibia are tall narr ow bones. Additionally, the articular surfaces are segments of a circle so there are no restraining ri ms available in the sagittal plane and, consequen tly, no intrinsic stability. The skeletal architectur e is designed for mobility. This means that other stabilizing mechanisms are needed. At the hip an teriorly and the knee posteriorly a strong ligame nt stabilizes one side of the joint. By using hyper extension to align body weight on the opposite si de, the person is able to attain passive stability. No similar mechanism exists at the ankle or subt alar joints, however. Instead, here a free range of dorsiflexion-plantar flexion and inversion-eversi on exists. Thus, only through direct muscular co ntrol is the tibia stabilized over the foot. Passive stability is further challenged by the fact that the foot does not provide equal areas of support ante rior and posterior to the ankle axis. Posteriorly th e weightbearing segment of the heel is little mor e than 1 cm, for the significant factor is the roun ded contour of the tuberosities and not the full le ngth of the os calcis. By contrast, the anterior (fo refoot) lever that extends to the weightbearing su rface of the metatarsal heads averages 10 cm in a n adult. Thus, for optimum foot support (equal a nterior and posterior leverages), the body weight line (vector) must be anterior to the ankle joint. This increases the demand for active control of t he ankle and subtalar joints. During walking the trunk and limb segments are continually moving from behind to ahead of the supporting foot. Thus passive stability is a fleeti ng experience. At the onset of stance, flexion tor ques are created at the hip and knee that must be restrained by active muscular effort. As body we ight moves forward, this demand is gradually rep laced by passive support from tense fascias. Con versely, the demand for active ankle restraint (a plantar flexion force) does not begin until body weight moves forward of that joint axis. Once th e forefoot becomes the major area of support, m uscular response must increase rapidly. Thus the ever changing alignment of body weight is stabil ized by selective muscular The timing and intensity of each muscle's activit y are dictated by the relationship of body weight to the center of the joint that muscle controls. Th is is the torque created, a product of force X leve rage. The length of the lever (moment arm) is th e perpendicular distance between the body weig ht line and each joint center. Body weight is the basic force, but its effect is modified by the direc

tion in which it is moving. The composite effect is determined by measuring the instantaneous gr ound reaction forces. At the beginning and end o f stance, body weight drops rapidly toward the fl oor. The resulting accelerations increase the gro und reaction force to a value greater than the bod y weight. During the midstance period the body rises slightly as the limb becomes more vertical. This reduces some what the weight directed toward the ground. Conseq uently, the force demands presented to the muscles vary by both the loading experience and the alignme nt of body weight over the joints. Selective neural c ontrol and proprioception as well as adequate streng th are needed for appropriate muscle response. Energy conservation. The basic measure of effi ciency is energy expenditure per task performed. For walking this is oxygen used per meter travel ed. Oxygen is consumed as the muscles contract. Thus efficiency is improved by reducing the am ount of muscular effort required to walk. This no rmally is accomplished by two mechanisms: mo mentum is substituted for muscle action whereve r possible, and displacement of the body from th e line of progression is minimized. 1. Optimum use of momentum occurs during the person's natural gait velocity. That motion patter n requires the least energy expenditure per meter tra veled. Both a slower and a faster pace increase the e nergy cost. 20 2. Minimization of body displacement from t he line of progression is accomplished by coordinati ng pelvic, knee, and ankle motion to keep the relativ e limb length fairly constant throughout stance. 1,3, 2 1 At the onset of a double stance, body height is lo west because the two limbs are diagonal. Conversel y, the highest position occurs in the middle of single stance, when the supporting limb is vertical. For a normal adult step length of 70 cm the heig ht loss would be abrupt and ankle dorsiflexion of 22 degrees would be needed by the trailing limb. To reduce these extremes, normal gait involves t hree pelvic motions: lateral drop, transverse rotat ion, and anterior tilt. All three approximate 4 deg rees and follow the swing limb. The stance limb contributes by two actions. At the beginning of t he weightbearing period a reciprocal relationship between knee flexion and ankle dorsiflexion adj usts limb length as it moves from a diagonal to a vertical alignment. Also heel rise in the latter hal f of stance adds relative length to the trailing lim b. Through these actions the potential 7 cm displ acement is reduced to 5 cm, a 30% saving. joint motion. The interplay of progression, stan ding stability, and energy conservation results in a complex and continually changing relationship among the various limb segments as the body ad vances over the supporting foot and the toe is lift ed to clear the ground. Each joint performs a rep resentative pattern of motion. During stance the postural changes are induced passively by the inf luence of body weight. Swingphase motion depe nds on muscle action.

Ankle. Two periods of plantar flexion and dorsif lexion are experienced in each gait cycle (Fig. 46). At the onset of stance the ankle has a 90-degr ee position. As the heel is loaded, the foot drops into 10 degrees of plantar flexion. Then the actio n reverses and gradually reaches 10 degrees of d orsiflexion. At this time plantar flexion is resum ed, reaching 20 degrees by the end of stance, alt hough the latter arc of motion occurs in the doub le stance period when the limb is being rapidly u nloaded. With toe-off the foot is quickly raised t o neutral dorsiflexion and maintained in this posi tion throughout swing. Knee. The knee also experiences two phases of f lexion and extension in each gait cycle (Fig. 47). Beginning in full extension (or flexed 5% it r apidly flexes to 15 degrees. Then it progressivel y extends to neutral. With the onset of double sta nce, it again begins to flex. This action continues in swing to reach 60 degrees before extension is resumed. Hip. Only a single are of hip extension and flexi on occurs in each gait cycle (Fig. 4-8). As the fo ot strikes the ground, the hip is in 30 degrees of f lexion. Throughout stance there is progressive e xtension into 10 degrees of hyperextension. The n flexion begins in terminal double stance and co ntinues through most of swing. When the 30-deg ree posture is reached, it is maintained until stan ce resumes. PHASES OF GAIT The functional significance of each joint's motio n pattern at any point in the gait cycle is depende nt on the total limb requirements for effective pr ogression and stance stability. This is identified by subdividing the continuum of limb action acc ording to the tasks that must he accomplished. T he result is eight functional units. Each constitut es one phase of gait. Normal events have customarily been used to de signate the different gait phases. Although this w as adequate for amputees, many other types of di sability prevented the patients from accomplishi ng some of the key actions. The terms thus beca me meaningless. To avoid such confusion, a gen eric terminology was developed. Because it has proved universally applicable to normal, ampute e, arthritic, and paralytic patients, it is the system that will be used in the ensuing discussion. Because one gait cycle blends into the next in an endless fashion, any event can be selected as the starting point. Initial floor contact is the most co nsistent event in both normal and pathologic gait and, thus, will serve as the first gait phase. Normal function is the model for judging a patie nt's gait. Disability reduces the limbs' effectivene ss by altering their pattern of motion. The signifi cance of the observed deviations relates to the ch anges in total limb posture that occur during the individual gait phases. Thus the basis of gait ana lysis is to have a firm concept of limb function d

uring each gait phase, to know the purpose of the normal motion patterns, and to appreciate the pe nalties that disabled performance imposes. Stance To allow progression while also maintaining wei ghtbearing stability, the limb performs five disti nct tasks that define the phases of stance. Initial contact. Of primary concern is the way t he foot strikes the floor. Although this is a mome ntary posture, it is significant because of its influ ence on subsequent knee action. Heel strike with the foot at a 25-degree angle to t he floor is the normal occurrence. The ankle is in an approximately neutral position (perhaps plant ar flexed 3'). The knee is extended between 0 an d 5 degrees of flexion, and the hip is flexed 30 d egrees. At this moment the free drop of body weight cre ates a vertical vector passing through the heel. w hich is anterior to both the knee and the hip. Thr ee torques are generated: ankle plantar flexion. k nee extension, and hip flexion (Fig. 4-9). Control of both knee and ankle is critical to havi ng normal heel strike. Dorsiflexion of the ankle t o neutral is dependent on free joint mobility and active control by the pretibial muscles (tibialis a nterior, long extensors of the great and common tom and peroneus tertius). Knee extension is accomplish ed by quadriceps action. Hip position does not influence the mode of floo r contact but does determine the angle between f oot and floor. Loading response. Acceptance of body weight i n .A manner that assures limb stability and still pe rmits progression is the goal at this time. As weight is dropped onto the limb, a heel rocke r action is initiated that leads to two significant motion patterns. The action at the ankle precedes and contributes to that occurring at the knee. Ankle. After floor contact by the heel, the foot qu ickly drops into 10 degrees of plantar flexion in a ontrolled manner. The motion is initiated when b ody weight is applied to the foot at the dome of th e talus while floor contact is still at the tip of the os calcis. An unstable lever results from differenc es in bone length between these points. Strong act ion by the pretibial muscles retards the terminal a re of ankle plantar flexion, so forefoot contact is g radual. Thus, heel strike is heard but no foot slap. This action dominates the first 6% to 8% of the ga it cycle. While these sagittal motions are occurring, there also is transverse rotation at the subtalar joint.28 The point of heel contact is lateral to the middle of the ankle joint (Fig. 4-10). This creates a valg us thrust on the subtalar joint. As the foot respon ds, support for the talus is reduced. The talus fall s into internal rotation. The strong ankle ligamen ts carry the tibia arid fibula with the talus so the

entire ankle joint turns inward.18 Knee. Flexion of the knee to 15 degrees is initiat ed by the heel rocker action. As the pretibial mu scles contract to restrain ankle plantar flexion, th ey also draw the tibia forward. This is a rapid act ion, and it advances the leg faster than the thigh and trunk can follow. As a result the body weigh t line shifts posterior to the knee and a flexion to rque (moment) is induced (Fig. 4-11). Two types of muscle action result. There is incre ased quadriceps activity to restrain the rate of kn ee flexion. Conversely, no longer are the hamstri ng muscles needed to prevent knee hyperextensi on. Marked reduction of semimembranosus and semitendinosus activity is the response.'s Persist ence of the biceps fernoris (long head) probably relates to its external rotation action at the knee. Hip. Little changes in thigh position occurs duri ng the loading response. The large hip flexion m oment present with the impact of initial floor contact is reduced by two passive actions. Rapid realignmen t of the vector to the body center brings the weight li ne close to the hip joint axis (Fig. 4-11). An extenso r thrust created by propulsion of the limb through th e heel rocker advances the femur as well as the tibia. Active muscular restraint of the hip flexion moments is provided primarily by the gluteus maxi mus and adductor magnus. Both these muscles mark edly increase their activity after initial contact. Parti cipation by the hamstrings is reduced because of the ir actions at the knee. Midstance. Advancement of the body and limb over a stationary foot is the functional objective of this gait phase. As the other foot is lifted for swing, a period of s ingle-limb support begins. Maximum stability is gained by having the foot stationary and in total contact with the floor (heel and first and fifth me tatarsal heads). Ankle rocker action allows progr ession to continue, occurring through residual m omentum and that generated by the contralateral swinging limb. As body weight advances across the arch, the base of the vector moves from the h eel to the forefoot. This alters vector alignment a t the ankle, knee, and hip, with resulting changes in joint posture and muscle control (Fig. 4-12). Ankle. At the onset of single stance the ankle stil l is slightly plantar flexed (5). From this positio n there is gradual dorsiflexion. The basic are is fr om -5 to +5, with 10 degrees of dorsiflexion bein g attained just as the heel rises to initiate termina l stance. Thus an ankle rocker is created for body progression. Allowing the tibia to advance beyo nd the neutral position so body weight moves ov er the forefoot is the critical action. As the body vector moves anterior to the ankle, a dorsiflexion moment is created that would accele rate the rate of limb advancement if it were not c ontrolled. Judicious restraint is an essential com ponent of knee stability. The soleus responds by restraining the tibia's pro

gression. Assistance by the gastrocnemius reduc es the effort that the soleus must exert, but it also induces a flexion torque at the knee. While these two muscles are acting to avoid excessive tibial advancement, they are doing so in a yielding ma nner; thus the desired degree of ankle dorsiflexio n is attained. An available range and timely tibial restraint are the critical events during midstance. Knee. Knee flexion induced during the loading r esponse increases slightly, reaching its maximu m of 18 degrees just as single-limb support is ini tiated. Motion of the knee then reverses to progr essive extension, which depends on the tibia's being a ctively restrained by the soleus so the femur can adv ance at a relatively faster rate. At approximately the middle of the midstance phase the body vector mov es anterior to the joint center and an extensor mome nt is begun. The need for active muscular control is terminated. Quadriceps action is maximal at the ons et of midstance. It then progressively declines as the knee extends over the vertical tibia and advancemen t of the body vector lessens the flexor torque. Once t he vector becomes anterior to the knee axis, extensi on stability is provided passively and the quadriceps relaxes. Hip. Progressive decline in hip flexion and entry into extension allow the trunk to remain erect wh ile the limb becomes more vertical. These motio ns are accomplished passively. The onset of single stance, however, creates new demands in the coronal plane. Lifting the opposit e limb removes support for that side of the body (Fig. 4-13). The unsupported pelvis falls, creatin g quick hip adduction in the stance limb. This is rapidly limited to 4 degrees and then reversed by active abduction to the extent of slight overcorre ction. Hip abductor muscle activity is intense througho ut midstance while the extensors are quiet. Terminal stance. Forward fall to generate a pro pulsive force is the primary objective. Heel rise s ignifies the onset of this second phase of single s tance. Now the forefoot serves as the progressio nal rocker, with the body falling forward of its ar ea of support. This creates the primary propulsiv e force for walking. With the limb acting like a s poke in a wheel, the body's center of gravity dro ps slightly during advancement. Throughout ter minal stance the ankle and foot are the critical sit es of action. Ankle. At the onset of heel rise the ankle drops i nto the maximum dorsiflexion (10) occurring in stance. Motion then reverses to reach 5 degrees of plantar flexion by the end of single-limb supp ort. Hence stabilization in a relatively neutral po sition is the objective so the forefoot can act as t he propulsive rocker. Stability is accomplished by the triceps surae. W ith heel rise the body vector is concentrated at th e forefoot (Fig. 4-14). The distance between the vector and ankle joint axis generates a maximal

dorsiflexion torque. This must be restrained if th e ankle is to maintain its neutral position. Both t he soleus and the gastrocnemius respond vigorou sly,25 ceasing abruptly as the single-stance period is terminated and body weight is rapidly transfer red to the other foot. Foot. With body weight being applied at the an kle (talus) and supported by the forefoot, a stron g dorsiflexion torque is generated through the mi dfoot. Stability is gained by inversion. This posture is initi ated by the obliquity of metatarsal support. The line between the second and fifth metatarsal heads is 28 degrees anterior to the coronal plane.12 Inversion of the subtalar joint so changes the axes of the talonavi cular and calcaneocuboid joints that they cease to be parallel. This locks all the midfoot joints (transverse tarsal, intercuneiform, cuneiformcuboid, and metata rsal bases). Heel rise also initiates dorsiflexion at the metatar sophalangeal joint. While most of body weight i s concentrated on the metatarsal heads, the bases of the proximal phalanges contribute by enlargin g the support area. At the end of terminal stance the body is well forward and the metatarsophala ngeal (MP) joint dorsiflexes approximately 20 d egrees. All the foot and toe muscles are active. Inversion is preserved by the tibialis posterior and soleus. At the same time it is restrained by the peroneals (longus and brevis). The long and short toe flexo rs also support the arch by the compressive force that their longitudinal alignment provides. Passi ve arch support is gained from the plantar fascia, which is tensed as the MP joint dorsiflexes. Compression from the toe flexors and tension fr om the plantar fascia also stabilize the MP joints so the phalangeal bases can add to the base of su pport. Knee. With the tibia stabilized on the foot, forwa rd alignment of body weight passively extends t he knee. Maximum extension varies between 0 a nd -5 degrees. At the end of terminal stance, wh en the vector is at the margin of MP support, the knee begins to flex. Body weight is rapidly fallin g toward the other limb. There is no quadriceps action at this time, for knee extension stability is gained from the body vector's continually being anterior to the knee joint axis. Hip. Passive extension of the hip joint continues as body weight advances beyond the supporting foot and the trunk remains erect. By the end of st ance there is 10 degrees of hyperextension. The anterior joint structures are maximally stretched by falling body weight. This commonly stimulat es the iliacus to provide a restraining force. Ther e is no hip extensor activity during terminal stan ce. As body weight begins to fall toward the oth er limb the hip abductors terminate their action, f or passive abduction is induced. Preswing. Preparation of the limb for swing is t he purpose of the actions that occur during the p

reswing phase. Floor contact by the other foot in itiates this' interval of terminal double support. R apid transfer of body weight to that limb allows t he desired actions to follow. The critical area of response is the knee. Knee. There is rapid passive flexion to 45 degree s, which occurs because the body weight has roll ed so far forward on the forefoot rocker that the t ibia no longer is stable. As the tibia advances, th e knee joint axis is moved anterior to the body vector. A flexion torque is created (Fig. 4-15). There is no flexor muscle action. The quadriceps (mainly the rectus femoris) may react briefly to r estrain the rate of passive knee flexion if needed. Hip. Flexion of the hip joint is initiated with the recovery from hyperextension to neutral that occ urs during this phase. The iliacus, often accompa nied by the rectus femoris, is active. Ankle and foot. There is rapid ankle plantar flex ion to a 20-degree position, a passive event since all the significant musculature is relaxed at the ti me of contralateral foot contact. Only the flexor hallucis longus remains active. It sustains MP joi nt compression and restrains dorsiflexion while f loor contact is maintained. This is not a major w eight bearing obligation, for the load is primarily on the other foot. Swing Lifting the foot from the ground and limb advan cement followed by preparation for stance are th e objectives of the three phases of swing. Initial swing. Recovery from a trailing posture i s the task that is accomplished. This involves tw o critical actions: flexion of both the hip and the knee (Fig. 4-16). Hip. From the neutral position attained at toeoff the hip rapidly flexes to 20 degrees. Although th e iliacus is the major force advancing the thigh, t he need for speed generates assistance from the s artorius, gracilis, and adductor longus. Knee. The amount of knee flexion required for t oe clearance of the floor (60) is attained by addi ng 20 degrees to the 40-degree posture acquired during preswing. Despite the fact that this is a cri tical event, there is not a dominant flexion force. Momentum from the advancing thigh is supplem ented by action of the short head of the biceps fe moris and the sartorius and gracilis. Ankle. Dorsiflexion of the ankle is initiated, but only half the 20-degree plantar flexion present at toe-off is recovered in this brief time. Thus toe cl earance of the floor is not dependent on ankle do rsiflexion during the initial phase of swing. The muscles contracting quickly to lift the foot are th e tibialis anterior, long toe extensors, and perone us tertius. Midswing. As limb advancement continues, the changes in the tibial alignment make foot control critical for floor clearance (Fig. 4-17). Hip. Maximum flexion to 30 degrees is reached

by continued iliacus action. Knee. Relaxation of the flexor muscles allows th e knee to extend passively. This accelerates adva ncement of the leg and foot. By the end of mids wing, knee flexion (30) equals that of the hip an d the tibia is vertical. Ankle. Dorsiflexion to neutral is accomplished a nd then maintained. Verticality of the tibia conti nues the need for active control of the foot. The tibial is anterior and other pretibial muscles respond accor dingly. Terminal swing. Advancement is terminated an d the limb is prepared for stance. The critical eve nt is complete knee extension (Fig. 4-18). Hip. The 30 degrees of flexion attained in mids wing is maintained. For this purpose the iliacus c ontinues to support limb weight while the hamstr ings prevent further motion. All three muscles-se mimembranosus, semitendinosus, and biceps fe moris long head-exhibit peak activity at this time.

Knee. Because gravity must be opposed and onl y a brief time is available for this, extension of t he knee to neutral (0or -5) continues under acti ve control. The quadriceps provides the needed e xtensor force. All heads remain active. Simultan eous contraction of the hamstrings to decelerate hip flexion also prevents hyperextension of the k nee. Ankle. Continued neutral dorsiflexion is the basi c posture, but the foot may drop into slight plant ar flexion (3to 5) at the end of the phase. The p retibial muscles tend to diminish their intensity o f action as the semivertical position of the foot p resents a less demanding torque. PATHOLOGIC GAIT The strength, joint mobility, and coordination fo r walking represent only a fraction of normal lo wer-limb potential. Running, climbing, dancing, and lifting are far more vigorous activities that al so are readily performed by the ordinary person. When paralysis or tissue damage restricts a patie nt's physical ability, this reserve is spontaneousl y used for walking. Only when the loss exceeds t he ability to adapt or the effort becomes too stre nuous does the disability become visible. Thus it is useless to admonish a patient to try harder; the re is no reserve for anything more than a momen tary (if that) extra effort. Instead, if there is to be lasting improvement in the patient's gait, the clin ician must accurately identify the functional erro rs, correlate them with the nature of the patient's pathosis, and select the optimal corrective measu res. Gait errors Ankle and foot Inappropriate initial contact Low heel strike Flat foo t contact Forefoot contact (toe strike)

Excessive plantar flexion (any gait phase) Premature heel rise (loading response and midstanc e) Excessive dorsiflexion (any gait phase) Lack of heel rise (terminal stance and preswing) Varus (inversion) (any phase) Valgus (eversion) (any phase) Toe drag (any swing phase) Knee Inadequate extension (terminal swing through te rminal stance) Flexion limited, absent, or excessive (loading response, preswing, initial swing) Hyperextension (any stance phase) Varus (any phase) Valgus (any phase) Hip Inadequate flexion (swing phases through load ing response) Inadequate extension (midstance through preswi ng) Adduction-abduction (any phase) External-internal rotation (any phase) Past-retract (terminal swing) Pelvis Anterior tilt (symphysis down) Posterior tilt (symphysis up) Contralateral drop Ipsilateral drop Hike (ipsilateral elevation) Trunk Forward lean Backward lean Rotation (to right or left) Lateral lean The functional significance of these gait errors d epends on their timing within the gait cycle and whether they are a primary dysfunction or a com pensating action. To make the latter determinatio n, it is necessary that all the events occurring in t he phase he related. Gait phase abnormalities Before the tasks represented by each phase of th e gait cycle can be accomplished, specific eleme nts of limb mobility and muscle control are requi red. When physical impairment prevents the app ropriate response, characteristic patterns of dysf unction result. Although each deficit creates som e gait error, those that inhibit the patient's ability to progress or threaten weightbearing are the crit ical events. Compensatory action increases the e nergy cost of walking. Other events (e.g., midswing varus) may be more of a cosmetic than a functional concer n. Initial contact. Loss of the normal heel strike ge nerally is attributed to excessive ankle plantar fle xion, but this is an oversimplification of the prob lem. Knee posture also alters the alignment of the foo t with the floor. There are three possible patterns

of dysfunction: 1. A low "heel strike" results when loss of an kle dorsiflexion to neutral is the only problem (Fig. 4-19). Floor contact is made by the heel, but the foo t so nearly parallels the ground that the benefits of a heel rocker are lost. 2. Flat foot contact with the floor occurs whe n the knee is flexed even though the ankle is at neutr al. Step length and forward momentum are correspo ndingly reduced. 3. Forefoot contact, often called "toe strike," i ndicates combined ankle plantar flexion and knee fl exion. If the ankle equinus is rigid, the tibia will be driven posteriorly as body weight is dropped onto th e foot. A flexible ankle merely results in a loss of fo rward momentum. Loading response. Attempting to bear weight o n a flexed knee in the presence of a weak quadri ceps leads to total limb collapse. Patients who ca n substitute avoid this catastrophy by preventing knee flexion (Fig. 4-20). Through premature sol eus action, they have a low heel strike and restra ined tibial advancement. The femur is stabilized by increased hip extensor activity. A flexion contracture or late but sufficient quadr iceps response results in excessive flexion. When hip extensor strength is insufficient, the tr unk falls forward and cane or crutch support is n eeded. Midstance. Excessive ankle plantar flexion prev ents the body from moving forward. Both standi ng balance and step length are lost unless the pat ient can advance body weight by some other me ans. Knee hyperextension is used by those with a dequate joint mobility (Fig. 4-21). Forward trun k lean is the other possibility, but hip extensor d emand is increased. Premature heel-off preserve s the foot rocker action. This is used by patients with sufficient balance, a stable knee, and the vi gor to rise from a rigid foot flat posture. A knee flexion contracture prevents the passive extension that normally occurs during this phase. Quadriceps demand is correspondingly increase d. Terminal stance. Inadequate ankle plantar flexo r strength is the critical problem. As a result ther e is excessive ankle dorsiflexion. With tibial adv ancement not restrained, knee flexion persists. T his requires quadriceps action to preserve stance stability. Heel rise is lost and thus the body adva ncement usually provided by the forefoot rocker is lacking (Fig. 4-22). Although there is no subst itute for inadequate soleus strength, patients can reduce the demand by avoiding knee flexion duri ng the loading response. Preswing. Loss of passive knee flexion during t his period reflects functional inadequacies occur ring earlier. Excessive ankle plantar flexion prev ents the patient from attaining the limb alignmen t needed to initiate the desired knee flexion. Deli berate guarding against extensor muscle weakne

ss results in active locking of the knee (Fig. 4-2 3). The penalties of inadequate preswing knee fl exion are experienced during the initial phase of swing. Initial swing. Inability to flex the hip deprives t he patient of limb advancement. Patients may us e trunk and pelvic rotation to gain gross circumd uction as a limited substitution. Lack of adequate knee flexion causes the foot to drag on the floor (Fig. 4-24). This problem may reflect inability to flex the hip, for that is the primary source of kne e flexion at this time. Pelvic biking and vaulting by the opposite foot are means of attaining floor clearance. Midswing. Excessive ankle plantar flexion caus es toe drag (Fig. 4-25). Foot clearance commonl y is gained by increased hip (and knee) flexion t o lift the entire limb or by vaulting of the other li mb. Terminal swing. Inability to extend the knee ful ly leaves the limb in an undesirable position for stance (Fig. 4-26). Step length also is lost. Rapid and excessive hip flexion followed by quick retr action can indirectly extend the knee through tibi al inertia. This provides an improved loading pos ture but contributes little to step length since hip flexion is reduced. Pathologic patterns Patients with seemingly very different diseases may have similar abilities to substitute and even respond to common modes of therapy. By contra st, others will respond quite differently. This app arent inconsistency can be explained by correlati ng the functional requirements of walking with t he anatomic patterns of the pathologic disorders.
Table 4.1. Components of walking
Source of motion Articulated levers Awareness of motion needed Control of motion Energy Motor unit (muscles) Bones and joint Sensory system Central motor system Cardiopulmonary system

Components of function. Like every other phys ical task, walking involves five functional eleme nts. Each is provided by a specific anatomic syst em (Table 4-1), which may be selectively damag ed by the different types of injury or disease. Source of motion. Muscles provide the forces ne eded to create desired motion and restrain the un wanted influences of gravity and momentum. M uscle fibers, however, are so dependent on their i mmediate nerve supply that any functional classi fication must consider the two structures as one. As a result the human source of motion is the "m otor unit. Levers to translate force into motion. The skelet on, its complex articulations, and the connecting ligaments provide the needed mobile lever syste m. Joint anatomy dictates the directions in which the motion can occur. Bone length proportionall y magnifies the motor unit's actions. Fibrous tiss

ue flexibility determines the freedom to move. Awareness of motion needed. Information as to the instantaneous position, the velocity, force, an d direction of motion, and the physical effects of the action is continually sensed by peripheral rec eptors and transmitted through the sensory path ways to neural control centers. Control source to provide the desired motion. U pper motor neurons arise from centers that coord inate sensory input with the anticipated motion. In this manner the muscles contract with appropriate timing and int ensity. There are numerous sites within the brain and spinal cord where a pathologic process can i ntroduce control deficits. Energy to move. Muscles use oxygen to generat e the energy needed for force production. Availa bility of an adequate oxygen supply depends on t he condition of the cardiovascular and pulmonar y systems. Classification. Injury or disease of the structures essential for walking fall into an anatomic pathol ogic classification. This allows numerous types of seemingly different etiologies to he functional ly grouped under the following headings: 1. Structural impairment 2. Motor unit insufficiency 3. Combined motor and sensory i mpairment (peripheral) 4. Central control dysfunction 5. Energy lack Structural impairment. Freedom to move and at tain optimal alignment depends on fibrous tissue mobility, architectural accuracy of the bones, an d articular cartilage smoothness. Contractures, s keletal deformity, and arthritis are the pathologic states. Contractures. Loss of passive mobility through f ibrous connective tissue stiffening is the most co mmon gait deficit. Every component of the musc uloskeletal system is susceptible. The cause gene rally is profound inactivity during the acute phas e of illness or cast immobilization for early heali ng. The fibrous tissue composition of joint capsules, ligaments, and tendons is well recognized. Equal ly significant are the sheaths and multiple bundle s that encase each muscle fiber, the fascial apone uroses, and the basal layer of skin. The element within fibrous connective tissue that is sensitive to inactivity is the gellike proteoglycan matrix su pporting the collagen fibers. Collagen is virtuall y nonelastic (3% stretch), and thus the fibers allo w joint motion by folding and unfolding or chan ging their angular alignment with the helical patt ern. Lack of motion causes physiologic deteriora tion of the proteoglycan. Water and chemical co nstituents are lost. Greater force is required to re align the collagen fibers. Experimentally, measurable changes have been demonstrated within 2 weeks. 1 Further immobil ization also increases the number of collagen fib er cross-links, and rigidity is correspondingly inc

reased.2,27 Clinically, two levels of contracture formation c an be identified, elastic and rigid. In the normal s tate there is sufficient tissue mobility that the ex aminer needs only the force of one finger to carr y a joint through its full range. When additional effort is required, an elastic contracture exists. D uring walking, body weight may act as the stretc hing force. The patient displays a nearly adequat e range in stance, but a significant deficit appear s in swing. When the functional error persists thr ough both stance and swing, rigid contractures e xist. Persistent plantarflexion is the problem. Fifteendegree contractures are so common that they ten d to be overlooked. Yet this seemingly mild defo rmity can prevent a person from standing. It plac es the body weight far behind the foot. With the tibia tilted backward, standing balance is recover ed only by substitutive postures (Fig. 4-27). Kne e hyperextension is the simplest, but this is possible only in patie nts who naturally have such a range. Otherwise, for ward lean of the trunk is necessary. The demand on the hip extensors is correspondingly increased. Patie nts without adequate hip extensor strength must sup port their trunk weight with a cane, crutch, or walke r. Vigorous persons substitute with a heeloff posture. During walking, fixed plantar flexion alters the midstance-terminal stance mobility. Generally th e effects carry over into preswing, which results in a short step by the contralateral limb and redu ced gait velocity. A knee flexion contracture places the body weig ht behind the knee joint. Two problems result: in creased demand on the quadriceps and loss of sta nding alignment. The force requirements on the quadriceps during flexed knee stance have been measured on a cad aver model.17 There were two significant finding s: (1) Both the quadriceps forces and the knee joi nt forces increased in proportion to the flexion a ngle. When the experimental muscle force was r elated to normal quadriceps strength, the 15-degr ee angle proved to he a clinically critical thresho ld. The demand on the quadriceps in this positio n was 20% of their maximum normal strength. I ncreasing knee flexion to 30 degrees created a 5 0% demand (Fig. 4-28). (2) The functional differ ence was that muscles contracting at 20% of thei r maximum capability were in a fully aerobic sta te and thus had relatively indefinite endurance w hereas muscles functioning at the 50% level wer e utilizing anaerobic metabolism and the resultin g inefficiency reduced their endurance to a very few minutes.14 Patients with less than normal str ength suffer a proportionally greater limitation. To stand upright despite a knee flexion contractu re requires increased ankle dorsiflexion so body weight can he aligned over the midfoot. Patients lacking the necessary ankle range substitute with a heel-off posture. There also are corresponding amounts of hip flexion. During walking, termina

l swing, midstance, and terminal stance are the g ait phases that display this deficit. Inability to attain neutral hip extension places th e trunk weight anterior to the joint, creating a pr oportionally high demand on the hip extensors. P atients with a mobile spine can substitute with lo rdosis. Sufficient range generally is available onl y to persons who developed their disability in ch ildhood (polio or muscular dystrophy). When the needed ran ge is lacking, the trunk must be supported by crutch es. Skeletal malalignment. The contours of the artic ular surfaces and supporting shafts may become deformed at any age through disease or trauma. Within this spectrum the most susceptible period is the years of growth. In 1892 Wolff observed t hat changes in one's weightbearing pattern could alter the bones' internal architecture.4 Thus conti nued performance in the presence of a deformity would be costly. Children respond by progressiv e deformation as their growing tissues accommo date to the abnormal stresses experienced. From birth until maturity the bones are undergoing bot h longitudinal and circumferential patterns of ch ange that make them particularly susceptible to malaligned weightbearing (Fig. 4-29). The articu lar ends as well as the epiphyseal plates remain c artilaginous during most of the growth period. T his softer tissue is quite responsive to stress (Fig. 4-30). Asymmetric forces discourage new growt h on the compressed side while inducing overgro wth contralaterally. 10 Structural asymmetry res ults. Progression is subtle but persistent as contin ued weightbearing accentuates the problem. Adu lts lack the adaptability of growth tissues. As a r esult they react to excess stress by developing de generative changes that lead to pain and loss of f unction. Malaligned joints display such changes much earlier than is seen with normal aging. Musculoskeletal pain is caused primarily by tiss ue tension. It can be reduced by modifying joint posture and reducing muscle action. Hence the f unctional sequelae of pain are deformity and mu scle weakness. A common reaction to joint trauma or inflammat ion is swelling. As the fluid accumulates, the env eloping capsule becomes tense. Intraarticular pre ssure increases, and a painful situation is created. Motion adds further capsular tension. Thus, to minimize pain, the joint seeks a resting position with the least pressure. For the ankle this is 15 degre es of plantar flexion with the knee approximating 30 degrees of flexion (15to 60)8 (Fig. 4-31). Through the chronicity of arthritis or cast immobilization of a n acute injury, these protective postures may result i n functionally obstructive contractures as the conne ctive tissues adapt. The ability to walk is correspond ingly reduced. Swelling within the joint also inhibits muscle act ion. Pain is relieved by avoiding both the effects of motion and the compressive forces of muscle contraction. The reflex nature of this reaction ha

s been demonstrated experimentally.6 Progressiv e distension of the knee joint led to inability of t he quadriceps to contract. With anesthesia of the swollen joint, muscle action was restored (Fig. 4 -32). his finding confirmed the existence of a pro tective feedback mechanism. Unfortunately, if al lowed to persist, it would restrict the patient's abi lity to walk by the secondary deformities and mu scle weakness that followed. Motor unit insufficiency. Normal motion will n ot occur unless the appropriate muscle is active. This, in turn, depends on the health of its motor units (Fig. 4-33). Each motor unit consists of a lower motor neuro n and the group of muscle fibers it activates. Dep ending on muscle size and precision of action, th e number of muscle fibers related to a single axo n ranges from 10 to 1000. In the lower extremity the muscles contain about 500 motor units with 200 to 1000 muscles fibers in each.9 The lower motor neuron is the final common pat hway that translates the central neurologic signal s into motion. It consists of a cell body lying in t he anterior horn of the spinal cord and an axon t hat traverses the peripheral nerve to reach its app ropriate muscle. There the axon branches as exte nsively as the fibers it will innervate are widely s cattered.5 Motor end plates (myoneural junctions) transmit the axon's signals to the muscle fibers. Thus there are fo ur discrete sites within each motor unit that can be s electively injured by different pathologic entities. D estruction of any segment totally disrupts the motor unit's function for it performs on an all-or-none basi s. The result is flaccid paralysis, with the degree of muscle weakness proportional to the severity of the pathologic condition. Poliomyelitis is an acute viral infection that selec tively damages anterior horn cells. After the abru pt onset of gross paralysis there is gradual recov ery by the cells that were not completely destroy ed. Gains are most rapid during the first 3 month s. Further improvement in strength continues at a progressively reduced rate, with 95% of the final outcome attained during the first year.24 There is no typical pattern of paralysis. A few wi dely scattered muscles may be weakened, or ther e can be total paralysis of all four extremities. Int ermediate involvement exhibits some segmental characterization because cell bodies supplying th e different muscles tend to cluster. They lie in co lumns one to three segments long that overlap an d entwine in a fashion that makes several muscle s susceptible to the same local lesion 23 (Fig. 434). As a result the quadriceps, hip adductors, an d hip flexors (1,24) commonly have similar level s of paralysis. Another common grouping includ es the hip extensors, hip abductors, and ankle pla ntar flexors (L4-S2). Contractures are most likely to develop wheneve r the patient's activity level is too low. This is a c ommon occurrence during the acute stage. Later, as aging makes the patient less active, susceptibi

lity to connective tissue stiffening increases. The Guillian-Barre syndrome (infectious neuron itis) strikes the axons as they exit the spinal cord in the roots of the peripheral nerves. It is a rapidl y progressive but, fortunately, self-limiting infla mmatory disease of unknown origin. After a peri od of paralysis it typically resolves to full recove ry. The more severely impaired patients, howeve r, will have some residual disability. The paralyti c picture is similar to the one for patients with m oderate to severe poliomyelitis, except that the i mpairment is about the same bilaterally. Resoluti on is more complete, and recovery starts in the p roximal segments and progresses distally. Clinic al experience has demonstrated that both the ext ent and the rate of recovery can be inhibited by o veruse of the weakened muscles. In the lower ex tremity, extensors are most commonly strained. The course of spontaneous recovery limits these patients' contracture susceptibility to the initial a cute phase of gross inactivity. Muscular dystrophy is a bilaterally symmetric pr ogressive degeneration of the muscle fibers. The re are several patterns of involvement, each with a characteristic age of onset. The most common is pseudohypertrophic (Duch enne's), because of the disproportionally enlarge d calf muscles. Traditionally this has been an un explained artifact of the disease. Now it is thoug ht to represent work hypertrophy, since these mu scles are used with all available vigor to stabilize the knee despite weakened quadriceps and hip e xtensors. Fatty connective tissue replacement of the destroyed muscle fiber makes contracture for mation a significant factor in this disease. As the disease progresses, awkwardness changes to the typical gait deficits of localized motor unit loss. Further advancement of the paralysis and c ontractures limits the patient's substitution capab ilities. Myasthenia gravis involves the motor end plate s. The involvement is systemic and is managed medicinally rather than with orthoses. Its inclusi on in this discussion is merely to complete the pi cture of motor unit pathology. Strength requirements. The ability of patients wi th motor insufficiency to walk is determined by t heir muscle strength and passive joint mobility. Of concern are both the primary movers and thos e needed for substitutions. Strength loss with any of these diseases is propor tional to the number of motor units impaired. Be cause these patients have normal control, their st rength and passive range can be measured directl y. Manual muscle testing is the most common te chnique used. Interpretation of these descriptive grades (1 through 5, for trace to normal) was unc lear, however, until Beasley3 quantitated the valu es by tensiometer testing. He compared the stren gth of polio patients with varying patterns of we akness to that of normal children in the same age

group. Grade 4 (good) proved to be only 40% of normal, Grade 3 (fair) 15%, and Grade 2 (poor) a mere 5% (Fig. 4-35). Sharrard22 indirectly conf irmed the low value of Grade 4 in a spinal cord s tudy of polio patients who had died of respirator y paralysis. More than half a muscle's anterior h orn cells were absent before the manual tests dis played any weaknesses. Thus inability to accept full manual resistance represents a 60% rather th an a 20% loss of strength. This is functionally ve ry significant. Grade 4 muscles are able to meet t he regular demands of walking and climbing stai rs and ramps but have very limited ability to sub stitute for weakness elsewhere. The functional significance of muscle weakness depends on the demands imposed during walkin g. These vary markedly. The hip abductors and t riceps surae (soleus mainly) must have Grade 4 (good) strength for the patient to walk without a limp. Hip extensors and flexors need be only Gr ade 3 (fair). A quadriceps of Grade 2 and less (p oor to 0) still allows the patient to have an appar ently normal gait if the hip extensors and calf are normal. Patients reduce the demand by walking at a slower speed and use very subtle substitutio ns. With selective motor control and all sensatio ns intact, the remaining musculature can be mars haled to perform with maximum advantage. Bei ng acutely aware of even minor position change s, the patients are able to respond promptly and a utomatically with the proper adaptation. Timing and strength of substituting muscles are altered, so considerable disability can be absorbed with minimal or no limp. Visible substitutive posturin g thus indicates a major level of paralysis or cont racture. Orthoses are accepted as functional aids when the patient lacks an effective postural subst itute to relieve pain or reduce the energy cost to a tolerable level. Gait characteristics. Because patients with moto r unit insufficiency have such substitutive capabi lity, their gait is a mixture of postural adaptation rather than a direct display of their weaknesses. There are seven major muscle groups that deter mine these patients' ability to walk in an effectiv e manner. Inability to activate the muscle or the l ack of sufficient strength leads to a characteristic gait deficit or substitution. When the deficit occu rs in stance, there will be excessive motion unles s the need is reduced by substitutive posturing. During swing the gait error is insufficient motion that necessitates exc essive action in adjacent joints if the task is to be co mpleted. Weakness of the pretibial muscles (tibialis anteri or and long toe extensors) causes a dropfoot. Th e resulting disability begins in midswing and per sists through initial contact. Because all the post ures it causes are abnormal, this is the most readi ly recognized disability. During midswing the foot passively drops into pl antar flexion. A toe drag will result if the foot is not picked up by increased hip and knee flexion

(Fig. 4-36). Alternate substitutions are used whe n these actions are not available. The plantar-fle xed posture persists through terminal swing, and thus the foot is inappropriately positioned for sta nce. Differences in severity of the impairment re sult in three modes of initial contact: Most com monly, inadequate dorsiflexor strength causes a l ow "heel strike"; that is, the excessive plantar fle xion aligns the foot almost parallel to the floor. The marked footdrop that may develop in childh ood produces a forefoot contact because the pati ent also uses some knee flexion to position the f oot more vertically. When the dorsiflexor muscl es have sufficient strength only to support foot w eight, initial contact will be normal; but then the forefoot drops in an uncontrolled manner, causin g a "foot slap." This means that the pretibial mus cles cannot accept the added demand of restraini ng the heel rocker torque. Once a foot-flat positi on is acquired, there is no more evidence of dors iflexor weakness. In contrast to the lack of dorsiflexors, inadequat e strength of the ankle plantar flexors is the most overlooked disability. The postural changes that it creates are subtle, yet they are critical to gait e fficiency. Insufficient soleus (and gastrocnemiu s) strength allows excessive tibial advancement. The direct signs are excessive dorsiflexion in mi dstance and lack of a heel rise during terminal st ance (Fig. 4-37). The primary penalty, however, is persistent knee flexion. Uncontrolled tibial ad vancement deprives the quadriceps of a stable ba se on which to extend the knee. Instead, the mus cle must contract throughout the weightbearing period to support a fle xed knee. Fatigue from overdemand or inability to walk because of insufficient strength to meet this de mand is the penalty. Patients with combined quadric eps and soleus weakness substitute by avoiding the knee flexion that usually occurs during loading resp onse. They minimize the heel strike and prematurel y lock the knee. Loading the limb in the presence of insufficient quadriceps strength causes total flexion collapse of the limb. Most patients avoid this catastrophe by leaning forward so body weight is anterior to the knee joint (Fig. 4-38). The resulting posture i s a straight knee with excessive ankle plantar fle xion, hip flexion, and forward trunk. With a stro ng soleus and hip extensors the substitution may be very subtle. Premature ankle plantar flexion may be the only visible sign. Inability to flex the knee adequately in initial swi ng reflects weakness in the synergy between the short head of the biceps femoris, sartorius, and g racilis. Loss of momentum from hip flexor weak ness is another factor. Mild weakness of the hip extensors is evidenced by forward fall of the trunk at the onset of stanc e. Greater loss cannot be tolerated without substi tution. Patients accommodate by using lordosis t o place the body weight behind the hip joint axis (Fig. 4-39). Such posture, however, increases the

demand on the quadriceps. When this is not poss ible, cane or crutch support of the forwardly alig ned trunk is needed. Contralateral pelvic drop at the onset of midstan ce caused by weak hip abductors is the basic gait error. The trunk will fall to the same side if not restrained. To preserve standing balance, an ipsilate ral trunk lean (over or beyond the stance limb) is ini tiated before the onset of swing. This combination o f actions is called a Trendelenburg gait. When the p atient also has either iliotibial band tightness or a sh ort limb (to preset the pelvis), the pelvic drop is avoi ded. The resulting gait is called a gluteus medius li mp (Fig. 4-40). Advancement of the limb in swing is lost when hip flexors are lacking. Momentum generated by the pelvic rotation and rapid pelvic tilt (symphys is up) is substituted by persons with strong abdo minal muscles. Peripheral sensory and motor impairment. Su perimposition of a sensory loss on motor impair ment sharply curtails the patient's opportunity to substitute. The most common causes are cauda e quina-level spinal cord injuries and their congeni tal equivalent, myelodysplasia. Additional etiolo gies are toxic peripheral neuritis and injury of th e sciatic or posterior tibial nerves. Other periphe ral nerves in the lower extremity lack a function ally significant sensory component. Penalties of sensory loss. Patients with the same degree of motor unit loss as the person disabled by poliomyelitis will not walk nearly as well. Se nsory loss on the soles of the feet delays awarene ss of floor contact. Involvement at the ankles, kn ees, or hips denies the patient prompt knowledge of joint position. Alternate sources of positional i nformation are not wholly satisfactory. The infor mation is incomplete and late arriving. To see th eir feet, patients must lean forward (Fig. 4-41). T his requires hip and trunk extensor control that may not exist. Crutch balance is compromised a nd the actual site of contact still is not visualize d. Sensory input from normally innervated proximal areas also is a limited su bstitute. The distance between floor and reacting joi nt is so great that postural imbalance occurs more q uickly than the body can respond. As a result, comp ensatory action may be initiated too late to be effecti ve or demand more strength than is available. Loss at even one joint (the ankle) presents a measurable i mpairment and challenge to muscle strength. With g reater areas of involvement, the disability rapidly ex ceeds the patient's ability to compensate sufficiently to use walking as the daily mode of ' travel. Orthotic support of paralyzed insensitive limbs adds stability but offers no sensory input unless the appliance exte nds onto an innervated area. Consequently, many pa tients still lack the information necessary to know w here and how much to move promptly and easily. T heir gait is correspondingly slow and inefficient. W hen the sensory impairment is an irritative one (as o ccurs with toxic neuritis), pain, tingling, and other u npleasant sensations add to the problems of sensory

loss. Standing and walking are avoided because the soles of the feet, being the most sensitive areas, are stimulated as body weight and motion rub them. Sh ear is more irritating than pressure. Disability patterns. Whether acquired (trauma) o r congenital (myclomeningocele), an injury invo lving the lumbar and/or sacral segments of the s pinal cord or their roots results in a flaccid paral ysis not unlike that of poliomyelitis. The motor l oss is from anterior horn cell damage or injury to the corresponding axons in the peripheral nerve s. These segments also contain sensory fibers, w hich are included in the area of injury. In spinal cord lesions the more distal segments may escap e injury, creating areas of spasticity which add to the patient's difficulties in walking. (See pp. 95 t o 98 for details.) Arrangement of the anterior horn cells within the spinal cord and axons in the lumbosacral plexus anatomically groups muscles by neurologic seg ments. As a result characteristic patterns of paral ysis and insensibility are seen at the different lev els of injury (Fig. 4-34). There are two basic gro upings-lumbosacral and lumbar innervation, wit h L4 being a transition root involved in both. Th e lumbar group also divided into low and high le vels of paralysis depending on the quality of L3 i nnervation. Depending on the extent of involvement, L5-S1 lesions (Fig. 4-42) produce varying degrees of p aralysis in the posterior musculature of the limb. Sensation on the sole of the foot, particularly the lateral side, is impaired. Injury of just the sacral segments markedly redu ces hip extensor control by total paralysis of the gluteus maximus and partial loss of the hamstrin gs. Distally there is a severe weakening of the so leusgastrocnemius complex and peroneals with c omplete paralysis of the toe flexors. The resultin g foot involvement leads to stiffness and inversi on deformities, with weightbearing concentratio n on the insensitive portion of the foot. Suscepti bility to skin breakdown is accentuated in myelo dysplastic children who develop equinus deform ities during their early period of inactivity. Inclusion of the fifth lumbar segment re duces hamstring and gluteus medius strength to an ineffectual level. At the foot there now is com plete paralysis of the triceps surae (gastroc-soleu s complex) with impairment of the tibialis poster ior. Loss of the hip extensors and abductors enco urages the development of flexion and adduction contractures. These complications not only incre ase the degree of trunk posturing needed to gain stance stability but also may deny the patient the opportunity to walk. Dependence on lordosis for hip extensor stability increases quadriceps dema nd as body weight be comes aligned on the flexo r side of the knee. The significance of triceps surae weakness corn monly is overlooked because the patient retains a strong quadriceps. Inability to restrain tibial advanc

ement in midswing causes persistent knee flexion th roughout the stance period. The more profound the s oleus weakness, the greater will be the degree of ex cessive dorsiflexion and associated knee flexion (Fi g. 4-43). Triceps surae paralysis also is likely to ind uce a severe calcaneal deformity in the growing chil d (excessive dorsiflexion with loss of plantar flexion range). Both body weight alignment and unopposed activity of the tibialis anterior create dorsiflexion tor ques. Calf weakness combined with reliance on the ha mstrings for hip extensor stability increases the demand on the quadriceps. Thus endurance beco mes a problem. Dorsiflexion-stop orthoses set to allow only 5 degrees of dorsiflexion significantl y improve postural control at all joints. The acqu ired tibial stability not only reduces knee flexion but decreases the amount of lordosis needed to st abilize the hips as well. Early use of such orthos es also delays the rate of foot and ankle deforma tion. Crutches are required when substitutive pos turing or deformities at the hip, ankle, or foot ex ceed the ability of the quadriceps to accommodat e. Community-level ambulation is the usual accom plishment, although the patient's gait velocity is l ess than normal, and should be the standard of a dequate orthotic and physical management of pa tients with L5-S1 lesions. Because the deficit with L4 (L3 functional level) lesions (Fig. 4-44) is so great, it is common prac tice to focus on the remaining musculature rather than the losses. As a result this pattern of paralys is is classified as an L3 functional level. With injury of the fourth lumbar segment, paraly sis of the hamstrings and gluteal muscles becom es complete and loss of the tibialis anterior has b een added. The patient now has no active hip ext ension or abduction. At the foot and ankle both s ensation and motor control are lacking. Strength of the quadriceps is compromised in proportion t o the amount of fourth lumbar root innervation it has. Lack of all hamstring activity increases the patie nt's susceptibility to flexion contractures. Inabilit y to decelerate hip flexion in terminal swing allo ws a longer step, making limb loading more prec arious. In addition, increased hip flexion during midswing is needed to accommodate the patien t's dropfoot. These several factors present a need for greater trunk lordosis to provide hip stability. Crutches become essential. No longer can these patients use unlimited lordosis as a substitute, be cause they also have reduced quadriceps innerva tion. As a result this vital muscle has a limited st rengthening capacity. Orthotic demands at the fo ot also are increased. Now the patient must acco mmodate to the lack of proprioception as well as the absence of all significant motor control at the ankle and subtalar joint. The critical determinant of these patients' ability to walk is freedom from obstructive contractures (hip and knee flexion, ankle plantar flexion). A h

ip flexion contracture increases the amount of lo rdosis needed for stance stability. Inability to ext end the knees fully increases the demand on the quadriceps, and foot deformities prevent assumi ng an upright posture. Involvement of L3 further weakens the quadrice ps. The ability to accept the lordosis needed for hip stability is correspondingly reduced. Patients accommodate by leaning forward and transferrin g the weight of the truck to crutches. This decrea ses their endurance, for the arm muscles now mu st work vigorously during both stance and swing. When quadriceps strength is less than Grade 4 (g ood), KAFO support is needed. Walking with lo cked orthoses increases the energy cost to a level that only the rare adult can tolerate. Functionall y, these patients fall into the next higher neurolo gic classification. The L2 functional level (Fig. 4-45) represents th e highest neurologic level contributing motor an d sensory function to the lower extremities. With only the L2 neurologic segments intact, active li mb control is limited to the hip flexors. Sensatio n is similarly restricted. The basic anatomic rule is that joint sensation is supplied by the same neurologic level a s the muscles crossing it. This allows the examiner t o estimate the patient's proprioception at the hip by t he strength of the hip flexor muscles. Few patients can attain an effective standing bal ance without some sensation in the hip. Freedom from flexion contractures also is critical, especia lly to patients with these high lesions. This prese nts a paradox. The presence of essential sensatio n parallels the strength of the hip flexor muscles. Having hip flexors as the only active musculatur e, however, introduces a high probability of cont racture development and the functional obstacles that accompany. Thus, despite the use of crutche s and bilateral KAFO support, an adult with para lysis at this level cannot be expected to accompli sh useful walking. The vigorous person may perf orm the motions, but the effort will be so costly t hat it serves only as an exercise, not effective loc omotion. Children, with their shorter levers, do much better particularly if they are started early. Hip, knee, or ankle deformities that deny the pati ent easy access to postural stance stability will re move all possibility of walking (Fig. 4-46). Despite having active hip flexor musculature, pa tients relying on bilateral KAFOs generally use a swing-through gait because reciprocal walking is slower and more costly of energy. This places a high demand on the arms. Swing-to gait represen ts limited arm capability. It can he considered no thing more than a form of exercise. Hence the ba sic requirement is easily attained passive hip ext ension (Fig. 4-47). This, of course, means the ab sence of any obstructive flexion (spasticity) or c ontracture). A second requirement is that the am ount of lordosis needed to stabilize the trunk and hips be minimal (Fig. 4-48). Abdominal muscle strength and spine mobility as well as hip extens

or range contribute to this factor. With reliance o n the arms as the locomotor system, these extre mities must have more than average strength. Ex cellent cardiopulmonary conditioning for energy is the final requirement. Early standards of pelvic control (i.e., fair-strength muscles being adequate if the patient were contractu re free) have proved to be unrealistic. A review of p atients with spinal cord injury who are independent walkers on a daily basis showed they had active con trol of one knee as well as hip flexor muscle action and sensation.11 Central control dysfunction. Spinal cord injury within the thoracic or cervical areas and brain les ions such as stroke, head trauma, or cerebral pals y paralyze patients through loss of central contro l. To varying extent there is disruption of the upp er motor neuron system with disturbance of the c entral sensory pathways. The motor units are stil l intact but no longer under direct voluntary cont rol. Instead, they react to primitive stimuli in an overt fashion. The result is modes of excessive motion that commonly are grouped under the ter m spasticity (Fig. 4-49). Similarly, sensory feedb ack signals may be missed or erroneously interpr eted. The intact central nervous system provides two b asic motor functions: (1) selective control and (2) modulation of primitive motor responses. Ea ch is critical for the motions that constitute norm al gait. Selective control allows the person to move one j oint (even one muscle) independently and to sele ct the direction, intensity, timing, and duration of that action. This is the basis of learned motor pat terns such as walking, dancing, and sports that la ter are performed by habit. Selective motor contr ol also determines the patient's ability to respond to manual muscle testing. During walking it allo ws the muscles of the hip, knee, and ankle to res pond in a precise manner to the series of postural demands that occur throughout each stride. Alth ough there is a gross pattern of having the extens ors active during stance and the flexors producin g the motions of swing, the individual muscles d isplay independent timing and levels of intensit y. Simultaneous action occurs only when there is coincidental demand. Otherwise, the activity is a synchronous. This is particularly apparent amon g the extensor muscles as they react to the dual d emands of stance stability and mobility. Activation of the hamstrings in terminal swing p recedes initiation of quadriceps activity. The oth er hip extensors, gluteus maximus and adductor magnus, delay their onset until they are needed f or limb stabilization in stance.15 At the ankle, act ivation of the plantar flexors is delayed until mid stance.25 During swing, it is the knee control that displays phasic independence. The flexors are ac tive in initial swing, and the extensors participate in the terminal phase. At the same time the hip f lexors and ankle dorsiflexors remain continuousl y active. The signals for selective control are car

ried through the pyramidal tract. It may be dama ged at any level within the brain or spinal cord. Primitive control sites, located at different levels within the brain and spinal cord, provide automa tic modes of muscle action through stretch reflex es, postural reactions, and basic synergies. Unde r normal conditions the influence of these lesser centers is not apparent because it is subdued by t he extrapyramidal cerebral pathways. The center s provide a background of simplistic action patte rns that allow selective control to respond with g reater speed and efficiency to the functional dem ands of the moment. When the upper motor neuron tracts that suppres s these primitive sources of muscle action are dis rupted, the lesser centers are now the instigators of overt actions. These responses still may be us eful in their timing and intensity are not too inap propriate; otherwise, they are obstructive. Five t ypes of primitive muscle control have been ident ified. Two are forms of hyperreflexia. Quick stretch no rmally causes a single brief motor response. The primitive response is clonus (spasticity in its pur e form). The muscles contract in a chain of short bursts. Slow stretch also elicits muscle action in patients with upper motor neuron lesions. This re action is a sustained contraction that is called rig idity. In a neurologically normal person there is no muscu lar response to a slow stretch; only connective tissue tension is challenged. Thus in the patient with an up per motor neuron lesion, contracture cannot be diffe rentiated from rigidity unless anesthesia, icing, or fa tigue has suppressed sensorimotor interactions at th e spinal cord level, which are mediated through the muscle spindle. The rate of stretch determines the fo rce experienced by the change in muscle length. In t he presence of dense contracture, quick stretch may elicit rigidity rather than clonus as part of the force i s absorbed by connective tissues. Two other primitive reflexes relate muscle tone t o posture. This, in turn, sets the muscle's sensitiv ity to stretch. Limb position is one determinant. Extension of the hip and knee induces tension in the basic extensor muscles (gluteus maximus, qu adriceps, and triceps surae). With limb flexion th ese muscles are relaxed and the flexors (includin g the ankle dorsiflexors) are primed. The 45-deg ree position is roughly the dividing line. Body po sition also markedly influences muscle tone whe n the vestibular signals (arising within the brains tem) lose their sublimation. Tone is minimal wh en the patient is supine. With the body upright th ere is a marked increase in extensor muscle tone, and standing introduces a greater change than sit ting. In the upper extremity it is the flexor muscl es that react. This means that clinical decisions r elating to the patient's ability to walk must be ma de with the person upright and the limb extende d. Fitting of orthoses also becomes posture depe ndent. Failure to recognize these postural influen ces causes the patient's problems to be underesti

mated and hence inadequately managed. The fifth source of primitive muscle control relat es to the locomotor center in the midbrain. This extrapyramidal source of muscle control allows t he patient to use the mass patterns of limb flexio n and extension voluntarily. The flexors can be r eciprocally activated for taking a step (Fig. 4-50) and the extensors then used to stabilize the limb for stance (Fig. 4-51). The synergistic muscles at the hip, knee, and ankle respond simultaneously and the pati ent lacks the ability to modify the outcome. As a res ult the gait is slow and lacks several motions that co ntribute to stride length and efficiency. All patients with upper motor neuron lesions are subject to varying mixtures of these five modes of dysfunction. Thus, similar gait abnormalities can be seen in patients with greatly different pat hoses. The etiologic categories also have some c haracteristic patterns of dysfunction. To avoid re petition, we will describe the major gait deviatio ns within the clinical category they best typify. It should be understood, however, that the same pr oblems also occur in the other types of upper mo tor neuron disability. Of particular concern is whether the disability is unilateral or whether both lower limbs are impai red. Bilateral involvement limits patients far mor e than twice as much as a unilateral lesion. Now the patient cannot call on a sound limb to substit ute for the deficiencies in the other. High spinal cord injury. As discussed in the prec eding section, patients with lesions above L1 hav e a total lack of limb sensation and motor contro l. When the lesion is in the thoracic area, there al so is trunk instability due to paralysis of the abd ominal and lumbar muscles. Persons with T6-9 lesions present a tantalizing p icture. They have normal arms and are highly m otivated. With practice and training they can acc omplish a swing-to and sometimes a swing-throu gh gait. The effort required to lift and throw on e's body weight with each step, however, prevent s this from being a practical mode of locomotio n. Adding a trunk support for stability does not h elp, for this merely lengthens the body lever that the patient must swing forward. Thus, to walk, patients with thoracic or cervical i njuries must have incomplete lesions; that is, so me selective control and sensation must remain. Most injuries result in bilateral dysfunction. Orth oses and crutch assistance generally are needed. Because patients with thoracic lesions have nor mal arm strength and grip, they can accept great er lower limb disability than can quadriplegic pa tients. This allows the thoracic-level patient to us e the primitive mass patterns profitably to supple ment small residuals of selective control. Spastic ity commonly is a major deterrent. Proprioceptiv e impairment varies widely. Bilateral loss of posi tion sense (proprioception) at the knees as well a s ankles seldom is compatible with effective wal king. Orthotic needs range from a KAFO-AFO c

ombination to no such assistance. Conversely, cervical lesions are likely to be less severe because the spinal cord has more freedom within in the vertebral canal. In this group of pati ents, loss of selective control is a greater proble m than spasticity. Lacking vigorous arm support, the ambulatory cervical cord patient generally ha s a disability characteristic of the L5-SI lesion (F ig. 4-52). Orthotic assistance usually is limited t o AF0s bilaterally. In addition to the gross distinction between thora cic and cervical lesions, transverse locations of t he lesion presents characteristic disability patter ns. Injury to just half of the spinal cord creates a Brown-Sequard syndrome. The ipsilateral limb s uffers a major proprioceptive loss whereas the c ontralateral limb is paralyzed. Anterior cord inju ry impairs motor control in both limbs but preser ves sensation bilaterally. There also is a central c ord lesion that generally results in profound disa bility. In less severe situations, selective control is spared. Because most spinal cord injuries are some mixture of the aforementioned distributions, there really are no typical patterns of dysfunction per level of injur y. Furthermore, asymmetry is common. The basic ability of the patient to walk will depe nd on how much proprioception and selective co ntrol remain. Spasticity may be a major obstructi ve force. All but the rare patient will need a whe elchair as well as appropriate orthotic assistance even if they have attained the limited community ambulation status. Adult hemiplegia. A cerebrovascular accident (C VA), acute trauma, or other lesion localized to o ne side of the brain commonly causes hemiplegi a. The arm and leg on the side opposite the brain injury are disabled. As a result limb control is a mixture of impaired-to- absent selective control, primitive locomotor patterns, erect posture reflex es, limb posture tone, spasticity, and rigidity. Alt hough the degree of disability varies markedly a mong patients, there are some characteristic patt erns of impairment. Excessive plantarflexion is the most common gai t error. The four possible causes are phase-relate d: 1. Inadequate dorsiflexor action during swing (midphase and terminal phase) can be an isolated pr oblem in the mildly affected patient. This dropfoot, as it is called, indicates a deficit in selective control. If there is no other significant problem, the patient e asily substitutes with excessive hip flexion, often to the extent of not accepting an orthosis (Fig. 4-53). 2. When there is sufficient dorsiflexion durin g midswing but excessive plantar flexion occurs dur ing terminal swing, the patient is exhibiting an exch ange between the flexor and extensor locomotor patt erns (Fig. 4-54). The latter ankle action is initiated b y extension of the knee in preparation for stance. De pendence on the extensor pattern for weight bearing stability will continue the excessive ankle plantar fle xion as long as the quadriceps is active (generally th

roughout the stance phases). Forward progression of the lim b and thus the entire body is correspondingly curtail ed (Fig. 4-55). Step length for the contralateral limb is shortened, and gait velocity reduced markedly. 3. Spasticity of the ankle plantar flexors cause s excessive plantar flexion in late stance. Stretch act ivates the muscle as body weight advances over the limb. 4. Contracture of the triceps surae leads to ex cessive ankle plantar flexion throughout both stance and swing. The deficits created by the other neurolo gic states are aggravated. Hence prevention of contr acture formation by early care is particularly signifi cant for hemiplegic patients. Posturing the ankle in excessive plantar flexion f rom initial contact through terminal stance with r eduction of the equinus during preswing is a sig n of weak but existing selective control in the ex tensor muscles. Swing-phase inversion of the foot (varus) occurs when activity of the tibialis anterior exceeds that of the toe extensors and peroneus tertius. 1. Dependence on the primitive flexor pattern for stepping is the cause. When swing-phase varus p romptly reverses to neutral foot alignment floor cont act, the abnormality is not functionally significant. I nversion of the foot during stance, however, present s a major threat to weightbearing stability. It also is a source of local skin pressure, pain, and ulceration. Varus without equinus results from excessive and pr olonged tibialis anterior activity. If the imbalance is due to profound weakness of the other muscles, a su pporting orthosis will be effective. If it is due to stro ng tibialis anterior action, however, the foot will co ntinue to twist within the orthosis. Surgical rebalanc ing is indicated. 2. A second cause of foot varus is postural accommodation to equinus. Because plantar fle xion contracture or spasticity prevents advanc ement of the body by ankle dorsiflexion, the a djacent subtalar joint yields. Inversion is due to the fact that the calcaneal insertion of the d ominating soleus is medial to the subtalar join t axis. This form of stance varus cannot be co rrected by an orthosis unless there also is acc ommodation of the equinus within the shoe. Inability to clear the ground at the onset of swin g (toe drag) results from inadequate knee flexion (Fig. 4-56). There are several possible causes. 1. Occasionally it represents the loss of preswing knee flexion due to persistent equinus d uring terminal stance. Hemiplegic patients lack suffi cient selective control and quickness of propriocepti on to substitute adequately. 2. More often the problem represents a direct loss of knee flexion. The quadriceps may obstruct k nee flexion by gross or localized spasticity. About 4 0% of the patients experience such a phase shift of t he rectus femoris that it participates in swing as a hi p flexor. 26 Because the muscle still lies anterior to the knee it incidentally obstructs knee flexion. The e ffective correction is surgical release of the muscle's

insertion into the quadriceps tendon. Within the extensor synergy the quadriceps is by far the largest muscle. Thus a proportional loss of strength in all muscles causes a more profoun d effect than at the ankle and hip. The resulting g ait errors are similar to those of patients with mo tor unit deficits, except for the absence of substit utive efforts. 1. Plantar flexor weakness allows excessive d orsiflexion (Fig. 4-57). As the tibia falls forward wit h advancement of body weight, a knee flexion thrust is created. 2. Weakness of the hip extensors allows the f emur to drop backward as the trunk falls forward be cause slowness of the gait provides no propelling m omentum. Again, a knee flexion thrust is created. 3. If quadriceps weakness prevents this muscle from accepting the added demands, the conspicuous gait deficit will be knee extension instability. The orthoti c answer, however, is an AFO and cane, not a KAF O. There are two reasons for this approach. By coun teracting the flexion thrust induced from the hip and ankle, the quadriceps demand generally is reduced t o a functionally acceptable level. If this is not suffic ient, the patient still will not be able to walk. Use of a KAFO necessitates walking with a locked knee, w hich requires more trunk and hip control than will b e present in such a severely involved hemiplegic pat ient. Inability to flex the hip in swing is accompanied by a lack of knee flexion and ankle dorsiflexion. Patients who retain strong trunk control through bilateral innervation may substitute with pelvic h iking and rotation. The others are denied the opp ortunity to walk. Having only one sound arm, th ey cannot gain adequate crutch assistance. In hemiplegia, motor impairment and sensory im pairment are unrelated. There may be independe nt involvement of either system. Comprehension and communication limitations, which are prese nt in some patients, make accurate determination of proprioception difficult. 1. The situation that most confuses the patien t, and frustrates the clinical staff, is a profound gene ralized sensory loss combined with minimal motor i mpairment. Although the patient can move limbs un der direct vision, this function is not automatically a vailable. It is not useful because the patient lacks sp ontaneous positional feedback; nor can assistance b e gained from orthoses. 2. Impaired body image is the other major sensory problem. The patient lacks awareness of the hemiparetic side of the body. Thus there is fai lure to accommodate for body weight when the wea kened limb provides inadequate stance support (Fig. 4-58). As a result, the patient falls toward the hemip aretic side rather than shifts toward the sound limb o r the assisting cane. Again, an orthosis cannot replac e this sensory deficit. Severe stages make it impossi ble to stand without physical assistance. Milder stat es cause an intermittent loss of balance, which make s walking dangerous.

1. Akeson, W.H., Woo, S.L.Y., Amiel, D., et al.: T he connective tissue response to immobility: bionrechanic al changes in periarticular connective tissue of the immobi lized rabbit knee, Clin. Orthop. Rel. Res. 93:356, 1973. 2. Akeson, W.H., Amiel, D., Meachanic, G.L., et a l.: Collagen cross-linking alterations in joint contractures: changes in the reducible cross-links in periarticular conne ctive tissue collagen after nine weeks of immobilization, Connect. Tissue Res. 5:15, 1977. 3. Beasley, W.C.: Quantitative muscle testing: prin ciples and applications to research and clinical services, A rch. Phys. Med. 42:398, 1961. Bick, E.M.: Source book of orthopedics, New York, 1 968, Hofner Publishing Co., Inc. 5. Burke, R.E., Levine, D.N., Saicman, M., and Ts airis, P.: Motor units in cat soleus muscle: physiological, histochemical, and morphological characteristics, J. Physi ol. 238:503, 1974. 6. deAndrade, M.S., Grant, C., and Dixon, A.S.J.: Joint distension and reflex muscle inhibition in the knee, J. Bone Joint Surg. 47A:313, 1965. 7. Dempster, W.T.: Space requirements of the seat ed operator: geometrical, kinematic, and mechanical aspe cts of the body with special reference to the limbs, U. S. Wright Air Development Center Technical Report 55-15 9, Dayton, Ohio, 1955, Wright Patterson Air Force Base. 8. Eyring, E.j., and Murray, W.R.: The effect of jo int position on the pressure of intraarticular effusion, J. B one Joint Surg. 46A: 1235, 1964. 9. Feinstein, B., Linderard, B., Nyman, E., and Wh ollart, G.: Morphological studies of motor units in normal human muscles, Acta Anat. 23:127, 1955. 10. Hatts, S.L.: Retardation of bone growt h by a wire loop, J. Bone Joint Surg. 27A:25, 1945. 11. Hussey, R.W., and Stauffer, E.S.: Spi nal cord injury: requirements for ambulation, Arch. Phys. Med. Rehabil. 54:544, 1973. 12. Inman, V.T.: The joints of the ankle, Baltimore, 1976, The Williams & Wilkins Co. 13. Inman, V.T., Ralston, H.j., and Torld, F.: Human walking, Baltimore, 1981, The Williams & Wi lkins Co. 14. Jorgensen, K.: Back muscle strength and body weight as limiting factors for work in the standing slightly stooped position. In Communications from the Danish Na tional Association for Infantile Paralysis, no. 30, 1970. 15. Lyons, K., Perry, J.K., Gronley, J.K., et al.: Tim ing and relative intensity of hip extensor and abductor mu scle action during level and stair ambulation: an EMG stu dy, Phys. Ther. 63(10):1597, 1983. 16. Murray, M.P., Drought, A.13., and K ory, R.C.: Walking patterns of normal men, J. Bone Joint Surg. 46A:335, 1964. 17. Perry, J., Antonelli, D., and Ford, W.: Analysis of knee-joint forces during flexed-kne e stance, J. Bone Joint Surg. 57A:961, 1975. 18. Perry, J.: Anatomy and bio mechanics of the hindfoot, Clin. Or- 25. thop. Re l. Res. 177:9, 1983. 19. Ralston, H.J.: Effects of im mobilization of various body segments on the energy cost of human locomotion, Proceedings, 2nd IEA Conference (Dortmund, W. Germany, 1964), Ergonomics (suppl.), p. 53, 1965. 20. Ralston, H.J.: Energy-speed relation and optimal speed during 27. level walking,

Int, Z. Angew. Physiol. 17:277, 1958. 21. Saunders, J.B.C.M., Inman, V.T., and Eberhart, H.D.: The major determinants in norm al and pathological gait, J. Bone Joint Surg. 35A:543, 1953. 22. Sharrad, W.J.w.: Correlatio n between changes in the spinal cord and muscle paralysis in poliomyelitis, Proc. R. Soc. Med. 40:346, 1953. 23. Sharrad, W.J.W.: The distribution of the perman ent paralysis in the lower limb in poliomyelitis, J. Bone Jo int Surg. 37B:540. 1955. 24. Sharrad, W.J.W.: Muscle recovery in poliomyelitis, J. Bone Joint Surg. 37113:63, 1955. Sutherl and, D. H.: An electromyographic study of the plantar flex ors of the ankle in normal walking on the level, J. Bone Jo int Surg. 48A:66, 1966. 26. Waters, R.L., Garland, D.E., Perry, J_ et al.: Stif f-legged gait in hemiplegia: surgical correction, J. Bone J oint Surg. 61A.927. 1979. Woo, S.L.Y., Matthews, Js.' Ak eson, W.H., et al.: Connective tissue response to immobili ty: correlative study of the biomechanical and biochemica l measurements of normal and immobilized rabbit knees, Arthritis Rheum. 18:257, 1975. 27.Woo, S.L.Y., Matterws, J.V., Akeson, W.H., et al.: Co nnective tissue response to immobility: correlative study o f the niomechanical and biochemical measurements of nor mal and immobilized rabbit knees, Arthritis Rheum. 18:2 57,1975. 28. Wright, D.G., Desai, S.M., and Henderson, W.H.,:Act ion of the subtalar and ankle joint complex during the stan ce phase of walking, J. Bone Joint Surg.46A:361,1964

Roger A. Mann The subject of the biomechanics of the foot and ankle is a complex one. The importance of the or thopaedic surgeon's having an intimate knowled ge of it is related to the fact that most of the clini cal problems presented to us, as well as their con servative and surgical management, are related a t least in part to the biomechanics of the body an d, in this case, to those of the foot and ankle. It is the functional biomechanics that influences our decision making with regard to the placement of the ankle after an arthrodesis, or the foot when c arrying out a triple arthrodesis. It is also reflecte d in our basic thinking when using a shoe lift or an arch support for various other clinical proble ms. In this chapter the basic biomechanical principle s will be correlated with clinical examples. As a person walks, the entire lower segment (i. e., the pelvis, femur, tibia, and fibula) undergoes rotation in the transverse plane.5,8 This is then tra nsmitted through the ankle joint and translated th rough the subtalar joint into the bones of the foo t. The foot is a unique structure insofar as it is fl exible during some phases of the walking cycle and rigid during others; it is flexible during swin

g phase and early stance phase and then converts into a rigid lever arm prior to toe-off. The body r equires a flexible foot to adapt to its external env ironment, which may he flat, uneven, or sloping, but it needs a rigid structure for push-off. Althou gh the foot has some inherent structural stabili ty, it attains most of its rigidity as a result of the external rotation of the entire lower segment, wh ich is then transmitted to the foot from the segm ents above. In this discussion, the mechanics of t hese changes will be described and correlated to represent a meaningful picture of foot functions. Normal walking. During normal walking (Fig. 5-1), each lower segment of the skeleton (compo sed of part of the pelvis, femur, tibia, and fibula) rotates in the transverse plane. The degree of rot ation progressively increases from the more prox imal segments to the more distal. When a person is walking on level ground, the pelvis rotates an average of 6 degrees, the femur 13 degrees, and t he tibia 18 degrees.5,8 The lower limb rotates inte rnally during swing phase and the first 15% of st ance phase. The direction is then reversed and ex ternal rotation begins, reaching its peak just after toe-off, when internal rotation again occurs. This transverse rotation is passed to the talus through its articulation with the tibia and fibula. Axes. The axis of the ankle passes just distal to t he tip of each malleolus and may be reasonably accurately estimated by placing one finger on ea ch malleolus. The axis of ankle rotation is directed laterally an d posteriorly in the transverse plane and laterally and downward in the frontal plane. The angle be tween it and the long axis of the tibia is approxi mately 80 degrees, with a range of 68 to 88 degr ees 4 (Fig. 5-2, A). In the transverse plane (Fig. 5-2, B) it is externally rotated 20 to 30 degrees w ith respect to the knee axis (which is perpendicul ar to the line of progression). The longitudinal axis of the foot (Fig. 5-2, C). w hich passes between the second and third toes, is internally rotated 6 degrees to the axis of the ankle j oint, with a range of 21 degrees of internal rotation t o 9 degrees of external rotation. Arthrodesis of the ankle. It is important in perf orming an ankle arthrodesis to consider the place ment of the ankle joint. 1. In the anteroposterior plane the ankle shoul d be placed in 5 to 7 degrees of valgus so the weight bearing line will pass medial to the midline of the ca lcaneus. When it is in slight valgus, the foot will ass ume a plantigrade position; if the ankle is tilted into some varus, weightbearing will be along the lateral border of the foot, causing increased pressure benea th the fifth metatarsal head, which often becomes qu ite symptomatic. In most male patients the ankle should be in a ne utral sagittal position insofar as dorsiflexion and plantar flexion are concerned. If the foot is place d in too much plantar flexion, the patient will ha ve a tendency to vault over it or walk with increa sed external rotation, which will then increase th

e stress on the medial aspect of the ankle and kn ee joints. In a woman who wishes to wear elevated heels most of the time, the ankle can be placed in 10 d egrees of plantar flexion. If the patient happens t o have motor weakness in the quadriceps muscle group, making the knee unstable, then the ankle joint should be placed in approximately 10 degre es of plantar flexion to help provide stability of t he knee joint by creating a backward knee thrust after heel strike in early stance phase. 2. Another factor to be considered in positioni ng the ankle at the time of an arthrodesis is the trans verse rotation. It is important to note carefully the n ormal opposite limb so the degree of external rotatio n of the ankle joint can be determined and the opera ted side placed in the same degree of transverse rota tion. After an ankle joint arthrodesis, dorsiflexion and plantar flexion are eliminated and this lost motio n is compensated for elsewhere, at a site more di stal to the ankle joint (i.e., through the subtalar a nd transverse tarsal joints). Fig. 5-3 demonstrate s the amount of motion that can occur within the midfoot region to compensate for an arthrodesis of the ankle joint. It is unfortunate that degenerat ive changes may occur in these joints secondary to the increased stress placed upon them. The axis of rotation of the subtalar joint is obliq ue.4 It passes from medial to lateral in the transv erse plane, proceeding from the distal portion of the foot to the proximal at an angle of 23 degrees to the midline of the foot, with a range of 4 to 47 de grees (Fig. 5-4, A). In the horizontal plane it passes at an angle of 41 degrees, with a range of 21 to 69 d egrees (Fig. 5-4, B). When the axis is studied, it can be seen to resemble an oblique hinge (Fig. 5-5). Thu s rotation imparted to the superior aspect of the talus will bring about rotation of the calcaneus in the opp osite direction. External rotation of the leg will prod uce inversion of the calcaneus. Internal rotation of t he leg will produce eversion of the calcaneus. As ca n be readily seen, the rotation in the subtalar joint is intimately coupled with the rotation of the lower seg ment. Thus the transverse rotation that occurs in the lower extremity passes across the ankle joint and is t ransmitted through the subtalar joint into the foot. If this joint fails to rotate, a certain amount of transver se rotation will occur in the ankle joint. If this is a lo ngstanding problem, a ball-and-socket ankle joint m ay result as the ankle attempts to take up the transve rse rotation that normally would be absorbed in the subtalar joint (Fig. 5-6). Motion that occurs in the subtalar joint (Fig. 5-7) is called inversion when the calcaneus is brought toward the midline of the body and eversion whe n the calcaneus is brought away from the midlin e. Passive and active inversion is approximately 30 degrees, and eversion about 10 degrees. The magnitude of inversion during the stance phase o f level walking is about 8 degrees in persons wit h normal feet and 12 degrees in persons with flat feet.9

In persons with cavus feet the degree of subtalar joi nt motion is less than that in normal feet. The degre e of eversion that occurs is roughly equal to the stat ed degree of inversion. In normal walking, eversion of the hindfoot takes place throughout the first 15% of stance phase, at which time inversion begins (Fi g. 5-8). The motion in the subtalar joint is passed thr ough the talus and calcaneus to the navicular and cu boid bones respectively. The subtalar joint complex (i.e., the subtalar and transverse tarsal joints) functions as an integrate d system. If motion in it is eliminated by a tarsal coalition, for example, then secondary changes c an eventually occur because the stress placed on the other joints is increased. In the tarsal coalitio n a large dorsal beak occurs on the talus as a res ult of the increased stress placed on the talonavic ular joint (Fig. 5-9). The transverse tarsal joint, which consists of the talonavicular and calcaneocuboid joints, is so co nstructed that any motion in the talus or the calc aneus, or both, will affect its stability.2 Dependi ng on the position of the hindfoot, two fundamen tal patterns are seen. When the hindfoot is everte d, the axes of the talonavicular and calcaneocuboid joints are parallel to each other, so relatively free motion c an occur about these parallel axes (Fig. 5-10). How ever, when the hindfoot is inverted, the axes of the t alonavicular and calcaneocuboid joints are divergen t so that some degree of restriction is present. When the periods of external and internal rotation of the lo wer limb are correlated with the positions of the hin dfoot, the lower limb can be seen to be in internal ro tation at heel strike, causing eversion of the hindfoot and decreased stability of the transverse tarsal joint (and therefore a relatively flexible longitudinal arch of the foot). As the lower segments start to rotate ex ternally during the stance phase, the hindfoot is inve rted and increased stability of the transverse tarsal j oint results, producing a more stable longitudinal ar ch of the foot. Remember: the navicular articulates with the thr ee cuneiforms and three medial rays whereas the cuboid articulates with the two lateral rays. Thu s, again, external rotation of the leg causes inver sion of the heel with consequent elevation of the medial side of the foot and depression of the late ral side while internal rotation of the leg produce s the opposite effect-eversion of the heel, depres sion of the medial side of the foot, and slight ele vation of the lateral side (Fig. 5-11). Arthrodesis of the subtalar joints. When an art hrodesis of the subtalar joint is performed, the p osition of the calcaneus is extremely important. The calcaneus should be placed in 5 to 7 degrees of valgus, which will permit the transverse tarsal joint to remain flexible. If it is into too much val gus, an impingement may occur between its later al aspect and the distal portion of the fibula. The re also may be increased stress along the medial aspect of t he foot and ankle. If the subtalar joint is placed in to

o much varus, the weightbearing line will be lateral to the midportion of the calcaneus, making the calca neus somewhat unstable and increasing the possibili ty of chronic sprains of the lateral ankle ligaments. Another effect of placing the calcaneus into varus is that it makes the transverse tarsal joint more rigid an d therefore the flexibility that should be within this j oint when the center of gravity of the body passes o ver the foot is decreased. Consequently the patient will either adopt a more external rotation gait on the involved side (which permits the body to roll over t he relatively stiff foot) or develop a mild vaulting ty pe of gait. If only the subtalar joint is fused, motion can stil l occur within the talonavicular and calcaneocub oid joints (transverse tarsal joint); but if either of these joints is arthrodesed, then motion in the ent ire joint complex will be clinically eliminated. M otion of the subtalar joint is dependent on the abi lity of the head of the talus to rotate within the n avicular, and of the calcaneus to rotate on the cu boid. If either of these joints is eliminated, motio n in the entire subtalar joint complex will be eli minated. For this reason it is extremely importan t in doing a talonavicular fusion to place the foot in a plantigrade position so as not to create an ab normal wear pattern on the medial or lateral aspe ct of the foot. Orthoses. The most important factor in construc ting an orthosis is proper alignment of the axis o f the ankle joint to assure freedom of movement. The ankle-axis alignment of the orthosis is based on a line connecting the inferior tip of each mall eolus and crossing the frontal and transverse pla nes. To the extent that it reflects the relationship between the longitudinal axis of the foot and the ankle axis, the degree of toe out must be taken in to consideration in the overall alignment of a sho rt-leg orthosis. The type of motion that occurs in the ankle joint (Fig. 5-12) is plantar flexion and dorsiflexion. Pl antar flexion takes place at the time of initial flo or contact (heel strike) and continues through ap proximately the first 15% of the walking cycle. P rogressive dorsiflexion then occurs until about 4 0% of the cycle, when again plantar flexion begi ns (Fig. 5-13). During the swing phase, dorsiflex ion of the ankle joint takes place until the time of heel strike, when plantar flexion again begins. The metatarsal break is the name given the obliq ue axis that overlies the metatarsophalangeal joi nts. It passes obliquely from the head of the seco nd metatarsal to the head of the fifth metatarsal (Fig. 5-14). The angle between it and the long ax is of the foot may vary from 50 to 70 degrees. 4 As can be seen, the rotation that occurs in the lo wer segment acts on the talus. The translation of this rotation through the oblique hinge of the sub talar joint is what rotates the foot. The changing of the axis of the transverse tarsal joint, along wi th the changes that occur distal to this joint, caus es a conversion of the flexible foot into a rigid ar ch system. If one of the segments is functioning i

n an abnormal manner, it can readily alter the ent ire gait pattern. Another clinical correlation that pertains to trans verse rotation of the lower extremity is the effect on this rotation by various orthotic devices. As mentioned previously, transverse rotation of the lower extremity occurs not just within the foot but i n the entire limb as well. Consequently motion withi n the subtalar joint has some effect on the amount of rotation that is occurring within the knee and the hi p. At the time of initial ground contact, when the cal caneus goes into rapid eversion, the tibia is internall y rotating at the knee and the femur is internally rot ating at the hip. If the amount of motion of the subta lar joint is decreased, then the motion in the tibia, an d hence in the knee, will likewise decrease. This is what occurs when a medial heel wedge, shoe insert, or various types of heel modifications such as the T homas heel are utilized. In essence, they decrease th e amount of calcaneal eversion by supporting the ar ea of the talonavicular joint to prevent it from collap sing at the time of initial ground contact. The thickn ess of the support placed under this area will determ ine how much rotation can be eliminated. This usual ly becomes clinically significant only in a person wi th moderately severe pronation of the foot, which in turn causes an increase in the amount of internal rot ation of the tibia on the femur. As has been noted, th ere is a large variation in the axis of the subtalar join t, and the inclination of this axis will determine the amount of inversion and eversion that can occur in t he joint. A flat foot has more subtalar joint motion t han does a normal foot, and conversely a cavus foot has less. Muscles. The muscles of the lower extremity pla y a vital role in its function. The extrinsic muscles of the foot or calf should b e viewed in relation to their relative positions ab out the axes of the ankle and subtalar joints (Fig. 5-15). The more distant a muscle is from the axis of rotation (Fig. 5-16), the greater will be its leve rage; and, conversely, the closer it is, the lesser will be its leverage. With this in mind, it become s obvious that the muscles posterior to the ankle axis are the plantar flexors whereas those anterio r are the dorsiflexors; those medial to the subtala r axis are invertors, and those lateral are evertors (Fig. 5-17). Furthermore, it becomes clear that m uscles posterior to the ankle axis and medial to t he subtalar axis are plantar flexors and invertors whereas those anterior and medial to these axes are dorsiflexors and invertors. In patients with a specific motor loss, a diagram such as this can be of assistance in predicting the type of deformity that will probably result. For e xample, loss of function of the muscles anterior t o the ankle axis will lead to overpull by those po sterior to the axis and hence a dropfoot whereas l oss of function of the tibialis posterior, which is j ust behind the ankle joint axis and. the most med ial of the inverters relative to the subtalar axis, w ill result in overpull by the muscles lateral to the subtalar axis (peroneus brevis and peroneus long

us) and thus give rise to a valgus heel deformity with slight decrease in plantar flexion strength. By thinking of the muscles in relation to the joint axes, the clinician can predict more accurately th e type of deformity and make a better decision fo r possible tendon transfers. The activity of the anterior compartment muscle s (the dorsiflexors) occurs basically during swin g and in the early stance phase (Fig. 5-18). Their function is to dorsiflex the ankle joint during swi ng phase and to control plantar flexion after initi al ground contact. If they fail to do this, a dropfo ot will occur with a resulting steppage-type gait. A steppage gait compensates for the loss of ankle dorsiflexion by in creasing the amount of flexion of the hip and knee j oints so the foot can adequately clear the ground. If sufficient dorsiflexion cannot be achieved because o f weakness in and about the knee and hip joints, the n toe clearance is possible only by circumducting, a bducting, or externally rotating the entire limb. The activity of the posterior compartment muscl es occurs basically during the midstance portion of the gait cycle. Their function is to control the forward motion of the tibia over the foot, which i s fixed on the ground.6,7 If they fail to do this, the ankle joint will assume a position of full dorsifle xion after initial ground contact since that is the only stable position of the tibia on the dome of th e talus. Because of this position of the ankle, incr eased flexion of the knee will occur and result in a crouch gait. It is the controlled dorsiflexion of t he foot on the tibia by the posterior calf group th at permits the second period of knee extension to occur during the midportion of the stance phase. This extension is made possible by the fact that, with the tibia stabilized at the ankle, the knee can be brought into extension as the body moves for ward over the fixed foot. In considering any type of tendon transfer about the foot and ankle, it is important to remember w hich are the stance-phase muscles and which the swing-phase. The stance-phase muscles all lie po sterior to the ankle joint axis whereas the swingp hase muscles lie anterior to the axis. A phasic tra nsfer that is selected from a muscle in the same p hase will function more readily than a nonphasic transfer. The nonphasic transfer can be retrained to work in a different phase, but unfortunately th is is not always successful. The activity of the calf group of muscles occurs basically during midstance and in the terminalsta nce phases until toe-off. In a normal individual the intrinsic muscles of th e foot (those arising from and inserting within th e foot itself) as a group tend to be active from th e middle of midstance until toe-off. In a person with flatfeet they demonstrate a longer period of activity. Stabilization. There are two mechanisms that st abilize the foot itself and are not directly related

to the aforementioned angular rotations of the lo wer limb. 1. The plantar aponeurosis, arising from th e inferior tubercle of the calcaneus and passing forw ard (Fig. 5-19), divides into bands that circle the fle xor tendons and insert along the joint capsule into th e base of each proximal phalanx. The combination o f plantar aponeurosis and metatarsophalangeal joint capsule is known as the plantar pad. The plantar apo neurosis has essentially a fixed origin and insertion. As the metatarsophalangeal joints are brought into a n extended position, beginning after midstance (heel -off) and lasting until toe-off, the plantar aponeurosi s is wrapped around the metatarsal head and a relati ve shortening of the aponeurosis ensues. By this me chanism, the metatarsal head is stabilized and the ar ch of the foot raised without any muscular action pe r se. The mechanism has been likened to a windlass and is most effective for the great toe and least effec tive for the small toe. 2. The talonavicular joint, consisting of a convex tal ar head and a concave navicular surface (Fig. 5-20), is shaped like an elliptical paraboloid. When increas ing force is exerted across it during heel rise and toe -off, it becomes mechanically stable. Absorption of impact. One essential function of the foot and ankle is absorption of the impact of striking the ground. When a person walks, the in itial ground contact creates a force of approxima tely 80% body weight, following which there is a peak force of 115% (Fig. 5-21). When the pers on runs, initial impact on the ground is 150% of body weight and the peak force can reach some 275%. The basic mechanisms by which this impact is a bsorbed are the same for walking and running. O nly the magnitude of the forces and the joint mot ion that occurs are increased. At the time of initi al ground contact, motion within the hip, knee, a nkle, and subtalar joint helps to absorb the impac t. In a person with flatfeet. hyperpronation may occur at the time of initial ground contact that, b ecause of laxity of foot ligaments, can create clin ical symptoms about the foot and ankle. The con verse of this, the person with cavus feet, involve s decreased motion in the subtalar joint. When th e cavus foot impacts on the ground, there is less motion within the subtalar joint and hence the jo ints of the lower extremity. As a result less energ y is absorbed. Clinical symptoms characteristical ly develop because of the increased stress placed upon the musculoskeletal system. Events of a walking cycle. Initial floor contact (heel strike) begins the complex sequence of the walking cycle (Fig. 5-22). The lower segment undergoes rapid internal rota tion until foot-flat is achieved at 15% of the cycl e. To place the foot in a plantigrade position, the ankle joint rapidly plantar flexes. The heel is in a n everted position (through subtalar joint functio n), and the forefoot remains flexible (through tra nsverse tarsal joint function) as it adapts to the gr

ound. The pretibial muscles are active throughou t the first 15% of the stance phase. There is no ac tivity in the intrinsic muscles. At approximately 15% of the walking cycle (midstance) the directi on of rotation of the lower segment is reversed; e xternal rotation of the lower segment and inversi on of the hindfoot begin. Dorsiflexion of the ank le joint now starts, followed by electrical activity in, the posterior calf muscles. The intrinsic musc les in persons with flatfeet become active, but no activity is present in persons with normal feet un til 30% of the cycle. Heel rise follows at 35% of the cycle. From the beginning of hindfoot inversi on until the time of toe-off, there is progressive s tabilization of the transverse tarsal joint and the l ongitudinal arch. The posterior calf and intrinsic muscles remain active throughout the rest of stan ce phase until toe-off. As the foot is loaded, the convex head of the talu s is firmly seated in the concave navicular. The p lantar aponeurosis exerts its force on the arch as the body weight passes over the foot and the toes are brought into extension. Just prior to toe-off, t he lower segment has reached maximum externa l rotation and the hindfoot is in a position of max imum inversion. The axes of the transverse tarsal joint are divergent, the talar head is firmly seated in the navic ular, intrinsic muscle activity has reached its peak, a nd the activity in the musculature of the posterior ca lf is at its maximum. All these mechanisms have one common result: stabilization of the longitudinal arch of the foot a t the time of lift-off. As soon as lift-off starts, int ernal rotation of the lower segment begins with a ssociated hindfoot eversion. The eversion of the hindfoot unlocks the transverse tarsal joint and i n turn the longitudinal arch of the foot. No activi ty is present in either the intrinsic muscles of the foot or the posterior muscles of the calf. The foot once again has become a relatively flexible struc ture. The internal rotation of the lower segment c ontinues during the swing phase and does not re verse itself until foot flat has been achieved at 1 5% of the new walking cycle. REFERENCES
1. Close, J.R., and Inman, V.T.: The action of the s ubtalar joint. Univ. Calif. Prosthet. Devices Res. Rep. Se r., no. 11, issue 24, May 1953. 2. Elfunan, H.: The transverse tarsal join t and its control, Clin. Orthop. 16:41, 1960. 3. Hicks, J.H.: The mechanics of the foo t. II. The plantar aponeurosis and the arch, J. Anat. 88:25. 1954. 4. Isman, R.E., and Inman, V.T.: Anthro pornetric studies of the human foot and ankle, Bull. Prost het. Res. 10:11, 1969. 5. Levens, A.S., Inman, V.T., and Blosser, J.A.: Tr ansverse rotation of the segments of the lower extremity i n locomotion, J. Bone Joint Surg. 30A:859, 1948. 6. Simon, S.R., Mann, R.A., Hagy, LL--- and Lars en, L.J.: Role of the posterior calf muscles in normal gait, J. Bone Joint Surg. 60A:465, 1978.

7. Sutherland, D.H.: An electromyographic study of the plantar flexors of the ankle in normal walking on th e level, J. Bone Joint Surg. 4BA:66, 1966. 8. Sutherland, D.H., and Hagy, LL: Mea surement of gait movements from motion picture films, J. Bone Joint Surg. 54:787, 1972. 9. Wright, D.G., Desai, M.E., and Henderson, B. S.: Action of the subtalar and ankle-joint complex during t he stance phase of walking, J. Bone Joint Surg. 46A:361. 1964.

Terry R. Light

The human hand is an endlessly adaptable organ whose unique capabilities are the result of evolut ionary modification. Manipulation of objects wit h the forelimbs while standing or walking is imp ossible for quadripeds. As four-legged locomoti on evolved into bipedalism, the forelimbs were f reed to explore and interact with the environmen t. Many activities that are perceived as simple han d functions actually arise from the integration of activities of the entire body, upper limb, and han d. The analysis of body motion in terms of mech anical forces is the domain of kinesiology, whic h considers motion as it occurs under living con ditions. Motion is studied as various activities ar e performed against extrinsic forces, such as gra vity, or against the resistance of objects that are grasped, pushed, or hurled by the upper limb. St eindler 14 has emphasized that in many situation s muscles are primarily used to achieve "stabiliz ation and equilibrium rather than free motion." He points out that skeletal stabilizing efforts, oft en not apparent as visible motion, play an essenti al role in maintaining museuloskeletal balance. This chapter focuses on major patterns of upper l imb activity and delimits the mechanical and no nmechanical factors fundamental to effective act ivity. The importance of sensory function, inusel e strength, and skeletal integrity is outlined. It is hoped that through an appreciation of these elem ents, logical orthotic prescriptions may be formu lated. THE HAND AS A SENSORY ORGAN The hand acts as a vital probe to detect pressure, texture, temperature, moisture, vibration, and pai n in its environment. Sensation is critical to its f unction. Individuals usually bypass subsensate s kin areas, preferring to utilize functional patterns that incorporate skin regions with best sensation. Patients with median sensory loss often ignore a well-controlled thumb, choosing instead to use si deto-side pinch between the sensate ring finger a nd little finger.

The ability to perceive deep pressure allows an a ppropriate grasp to be maintained on an object. Regulation of the strength of pinch and grip is di ctated primarily by sensory nerve endings within the pulp of the digit rather than by muscle spindl e fiber tension. 3 In lower motor neuron lesions (e.g., a nerve laceration) sensory loss is accompa nied by a loss of sweating. This absence reduces friction at the fingertips and thus further increase s the difficulty of holding objects between dener vated digits. By contrast, in upper motor neuron lesions (e.g., spinal cord injury) sweating is not i mpaired. Normal sensory awareness implies a synthesis of visual and tactile information. This normal overl ap allows the typist to feel the keys of the typew riter while watching the results on the paper in th e typewriter carriage. Such integration of multipl e sensory cues provides optimum hand function. When one form of sensory input is impaired, ove rlapping input frequently compensates. Individu als with loss of tactile awareness are often able t o compensate partially for their loss by direct vis ion. Conversely, blind persons can focus on the sensory cues of Brail le letters to compensate for the absence of sight. Unexpected explosions may deprive the youngst er playing with fireworks, the laboratory technici an working with chemicals, or the soldier at the battle front simultaneously of both sight and han ds. These unfortunate individuals are virtual sens ory cripples, since their ability to compensate for visual loss through tactile clues is practically abo lished. Objects may be grasped only by using the stumps of the upper limbs simultaneously. Prost hetic devices that cover the residual limb further hamper these patients by rendering the limb inse nsate. The Krukenberg procedure, 15 in which th e forearm muscles are split apart and surfaced wi th sensate skin, may provide a reasonable alterna tive in such cases, allowing these patients to rega in single limb prehension. Routine techniques of orthotic management must be critically evaluate d in the blind quadriplegic or paraplegic patient. Gloves can be a mixed blessing. Although they may have a surface with greater friction that shie lds against some highfrequency vibrations, 17 th ey substantially alter the quality of sensory input by eliminating direct skin contact and thus lead t o the inadvertent use of abnormally high grip pre ssures. 16 SKELETAL ORGANIZATION Proximal stability Proximal stability, essential for secure hand plac ement, demands more than simple shoulder cont rol. Spinal stability with attendant trunk control i s actually the first essential for freeing the upper limb to perform effective prehensile activity. If t he arms are being used to hold crutches or a wal ker, the hands cannot be spared for other activit y. The paralyzed patient who uses a wheelchair i

s particularly vulnerable to being deprived of pot ential hand function in the presence of trunk inst ability. Many wheelchair-bound patients are rela tively well balanced in a static sitting position, b ut they are destabilized by a simple forward shift of their center of gravity as occurs when the com bined mass of the upper limb and the object bein g held is shifted anterior to their sitting center of gravity. The arm must be retracted and the objec t surrendered, or these persons may tumble out o f the wheelchair. Many will hook one arm over t he back or side of the chair for stability, eliminat ing the potential for bimanual function (Fig. 61). If hip or spinal extensor muscles are ineffecti ve, the wheelchair-bound patient must be stabiliz ed by a reclining backrest, retaining strap, or oth er spinal support so both upper limbs can be libe rated. Systemic disease can also limit the sphere of upp er limb activity. Pulmonary dysfunction has an a dverse effect on hand function, since the respirat or-, cripple may actually rest on the elbows whe n sit"ting. This posture permits the shoulder gird le muscles to assist in respiration. In the wheelch airbound respiratory cripple the hands are limite d to functioning within a markedly constrained a rea dictated by a table or forearm rests that supp ort the forearm. Objects can be manipulated only if they are directly in front of the individual.2 Although gravity tends to compress or coapt join ts of the lower limb, the sheer weight of the hand and arm affected by gravity tends to distract the j oints of the upper limb. Soft tissue constraints ar e particularly important for the most mobile joint of the upper limb, the shoulder. Limb mobility Effective functioning of the upper limb requires mobility as well as stability. The hand should be able to reach the mouth, hair, and perineum as w ell as the front of the body (Fig. 6-2). Kapandji' delineated seven degrees of freedom of the uppe r limb as it positions the hand in space. The shou lder pos sesses three degrees, the elbow one, and the wrist an d forearm together three. Shoulder Because the shoulder is the most proximal joint, it plays the primary role in limb orientation. Its s ubstantial mobility is enhanced by the lack of co nstraint inherent in the articulation of the spheric al humeral head with the shallow glenoid fossa. Flexion and extension occur around the transver se or coronal axis, abduction and adduction abou t the sagittal axis, and internal and external rotati ons about the vertical axis. Since the shoulder is so loosely constrained by its bony configuration, it is especially prone to dislocation when soft tis sue constraints have been disrupted and to sublu xation when musculotendinous coapting forces h

ave been altered by paralysis or weakness (e.g., a cerebrovascular accident). The principally used are of shoulder motion is in front of the body, a domain that allows visual in put to facilitate effective hand function (Fig. 62). A greater are is required for other bodily acti vities. Shoulder abduction is necessary for comb ing one's hair, though it is not essential for feedi ng or washing. Internal rotation is usually necess ary for posterior perineal hygiene, although com bined shoulder extension and adduction may be used to compensate in its absence. The shoulder girdle musculoskeletal complex pr ovides attachment and suspension of the upper li mb from the axial skeleton. Three articulationsth e glenoliumeral, acromioclavicular, and sternocl avicular-as well as the scapulothoracic interface give the shoulder mobility. In the upper limb the only direct contact of the appendage with the axi al skeleton is furnished by the sternoclavicular j oint. Motion through this and the acromioclavicu lar joints allows scapulothoracie motion either alone or combi ned with glenoliumeral movement. Scapular motion can be described in terms of the change in position of the scapula relative to the t horax. 4 Scapular elevation and depression are t hereby easily appreciated. Upward rotation of th e scapula is motion in which the inferior angle of the scapula moves anterolaterally, tilting the arti cular surface of the glenoid upward. Downward scapular rotation is the opposite motion in which the inferior angle moves medially, tilting the arti cular surface of the glenoid downward. Scapular protraction is movement laterally and forward ar ound the thorax. Scapular retraction implies mov ement medially and back about the thorax (Fig. 6-3). During the first 30 degrees of shoulder abductio n, scapulothoracic control is employed to stabiliz e the scapula so that all abduction takes place at the glenoliumeral joint.5 Through the are from 3 0 to 180 degrees, every 2 degrees of glenoliumer al motion is associated with 1 degree of scapulot horacic motion. Thus, in full abduction 130 degr ees of motion occurs at the glenohumeral joint a nd 50 at the scapulothoracic interface. Elbow The elbow has but a single degree of freedom: fl exion and extension. Its limitation to this are is g overned primarily by the osseous contour of the olecranon and trochlea. Recurrent dislocation of such a constrained joint, acting through a single plane, is infrequent. Because the elbow has but a single are of motion, it has been likened to a cali per functioning efficiently to regulate the distanc e between the trunk and the hand. The unique ab ility of the elbow to alter the length of the limb i s critical to such fundamental activities as feedin g and perineal care. The biceps has been termed the primary feeding

muscle since it both flexes the elbow and supinat es the forearm to bring the hand to the mouth. Its strength should be sufficient to lift the weight of the hand, forearm, and any object in the grasp of the hand against the force of gravity. 2 Although in the absence of an active triceps muscle gravit y may provide elbow extension, it is essential th at passive elbow extension be preserved if the li mb is to be capable of reaching the perineum. A ctive elbow extension is necessary for overhead placement as well for more vigorous activity suc h as using a walker or propelling a wheelchair. When triceps function is absent but full passive elbow motion is preserved, the elbow may be loc ked into a stable hyperextended position by shift ing the weight of the trunk toward that side. This technique creates a stable limb by shifting the ax is of weightbearing from the shoulder to the han d slightly posterior to the hyperextended elbow. 12 Forearm Three degrees of freedom-forearm rotation, wris t flexion-extension, and wrist deviation-govern t he orientation of the hand. The proximal and dist al radiouinar articulations allow forearm pronati on and supination. Because the ulna is stabilized proxirnally, forearm rotation occurs as the rAdiu s (with the attached carpus and hand) rotates aro und the ultia. Pronation is the ideal position for b ody weight support activity whereas supination i s important in feeding as well as for balanced su pport of objects in the palm. The usual mechanis m for attempting to compensate a lack of supinat ion is shoulder adduction. Shoulder abduction is useful in substituting for absent forearm pronatio n. Wrist Both dorsiflexion and palmar flexion as well a ra dial and ulnar deviation occur through the radioc arpal and interearpal joints. A limited degree of r otation is possible at the wrist, principally at the radiocarpal articulation. Because wrist dorsiflexi on passively tightens the finger flexors by a teno des's effect, it is a critical posture for grip activiti es. The ability of the wrist to palmar flex passive ly and to release digital grip is similarly importa nt in hands possessing limited active motor unit s. In ulnar deviation the thumb becomes aligned with the long axis of the radius, a particularly eff ective posture for holding tools. Characteristic wrist motion has been studied in t est subjects as they performed 52 standardized ta sks." The normal functional range of the wrist w as determined to be from 5 degrees of palmar fle xion to 30 degrees of dorsiflexion and from 10 d egrees of radial deviation to 15 degrees of ulnar deviation. Culinary skills required only 24 degre es of flexion-extension and 17 degrees of radioul nar deviation, with an average centroid of 12 deg rees dorsiflexion and 5 degrees ulnar deviation.

Eleven other activities of daily living required an average of 35 degrees of flexion-extension and 2 0 degrees of radioulnar deviation, with average c entroids o 10 degrees dorsiflexion and 1 degree ulnar deviation (Fig. 6-4). A tenodesis effect is present whenever an innerv ated or denervated musculotendinous unit traver ses more than a single joint. When the tension on a muscle is increased by the altered posture of o ne joint, there will be a reciprocal effect on the t ension across adjacent joints. For example, when the wrist is dorsiflexed the finger flexors are plac ed under increased tension as a portion of their t endinous excursion is stretched around the volar aspect of the radiocarpal articulation. The tensio n on the tendon is increased, and the fingers are passively pulled into a resting posture of increasi ng flexion at the metacarpophalangeal and interp halangeal joints. Hand Within the hand the metacarpophalangeal joints of the fingers as well as the carpometacarpal join t of the thumb are the least constrained joints- T his arrangement is analogous to the arm itself ins ofar as the most proximal joint is the least constr ained and thus allows the distal segment to subte nd the greatest are. The interphalangeal joints of the thumb and fingers are restricted to flexion an d extension whereas the metacarpophalangeal joi nt of the thumb can flex and extend and, to a lim ited degree, rotate. A variety of terms have been used to describe th e motion of the thumb1: 1. Flexion and extension occur at both the me tacarpophalangeal and the interphalangeal joints (Fi g. 6-5, A). 2. Radial abduction is movement of the thum b metacarpal away from the palm in the plane defin ed by the palm. Motion of the thumb metacarpal to ward the hand in that same plane is adduction (Fig. 6-5, B). 3. Palmar abduction (Fig. 6-5, C) is motion of the thumb away from the palm in a plane perpendic ular to the palm. 4. Retroposition is motion of the thu mb from palmar abduction toward a resting posture. 5. Rotation occurs at both the carpo metacarpal and the metacarpophalangeal joints. 6. Supination occurs when the thumb metacar pal rotates toward a position in which the nail of the extended thumb lies in the same plane as the nail of the extended fingers. 7. Pronation is rotation at the carpometacarpa l joint in which the thumb metacarpal rotates away f rom the plane of the other metacarpals. 8. Opposition (Fig. 6-6) is a complex motion that oc curs through carpometacarpal pronation, carpometa carpal palmar abduction, metacarpophalangeal joint flexion, and metacarpophalangeal joint pronation. It allows the palmar pulp surface of the thumb to face

directly the pulp of one of the other digits. NONPREHENSILE AND PREHENSILE ACTI VITIES Many systems of classifying upper limb activitie s confine their focus to prehensile activity in whi ch objects are grasped or pinched between the fi ngers and the palm and thumb. Important nonpre hensile activities should not be overlooked, how ever, since they can involve the hand in significa nt force transmission (through either pushing or punching). Limited force may be expended whe n the individual digits do nonprehensile activitie s such as tapping, striking keys of a typewriter, o r scratching or stroking. The upper limb also fun ctions in a limited number of activities that do n ot require participation of the hand itself. The ar m or forearm may be used for a pushing or block ing maneuver whereas the forearm itself can pro vide support for an object held against the chest. Nonprehensile activities The entire upper limb is often called on to functi on as a nonprehensile unit while maintaining its integrity under axial loading. Nonprehensile acti vities may involve the hand as a passive force tra nsmitter. Protraction, the process by which objec ts are pushed away from the body, requires stabil ity across the shoulder and elbow. Active elbow extension is coupled with forward flexion of the shoulder to provide the impetus for motion. The magnitude of force transmitted in this fashion is variable. Only a minimum amount of force may be required to push open a swinging door. In suc h an activity the momentum of the entire trunk a cts through the stabilized upper limb, with mode st augmentation provided through the triceps as i t extends the elbow while the door swings open. A much greater force on the flattened palm is re quired to support body weight, by both the exerc ising athlete doing pushups (Fig. 6-7) and the pa raplegic performing transfers. In the latter situati on the individual must exert considerable force t hrough the upper limb to move a major fraction of body weight against the force of gravity. The boxer's punch is an example of passive force tra nsmission through the clenched fiSt3: the force o riginates at the shoulder and elbow and passes ac ross the stabilized wrist. Prehensile activities Prehension is the process by which the hand gras ps and releases an object.'0 Cerebral control is re quired to approach an object, to initiate grasp, an d to interpret sensory feedback so the force of th e ultimate grip can be modulated and release triggered 7 The object must be securely held for effective preh ension to occur. Although the length of time that the object is grasped may be as short as the moment the ball is resting in the juggler's hand between tosses, t he time must be sufficient for friction to develop bet

ween the object and the skin for the momentary inte rruption of motion and maintaining control. By cont rast, a handball impacting against the palm of a mov ing hand is redirected in a decidedly nonprehensile action. Napierlo has categorized all prehensile activity a s either power or precision activities and has deli neated the characteristics of these two modes of hand functioning. Although some activities are c learly a mixture of both, and few activities fall in to neither category, this distinction is generally u seful in arialyzing requirements for the restitutio n of upper limb functional capabilities. Power grip. In power grip an object is held in a clamp with three sides-the partially flexed finger s, the palm, and the thumb (Fig. 6-8). The thum b, firmly adducted in the plane of the hand rather than in a posture of full opposition, proVides co unterpres sure. 'it inus Itunchons as a 'buttress. 3 This contrasts with precision grip, which occurs when an object is pinched primarily between the palmar aspects of the opposing, thumb and finge rs (Fig. 6-9). Power grip often requires the maintenence of a c onstant pressure on an object while the actual m ovement of the object occurs as a result of move ment of the shoulder, elbow, or wrist. An examp le of this would be the use of a hammer to drive a nail. The hammer is held securely in the palm while movement of the shoulder, elbow, and wri st causes it to strike the nail. Precision grip. By contrast, precision grip often involves the manipulation of an object held in th e hand. An example would be the surgeon's mani pulation of a microneedle holder. Optimum func tion occurs when the surgeon is relaxed and com fortably seated with the forearm supported. In thi s posture proximal support is maximized and fin e alterations of intrinsic and extrinsic muscle firi ng are combined for ideal performance. In precis ion activities the fingers are generally positioned in flexion. Small objects are held between the th umb and the index and middle fingers. The degr ee of abduction at the metacarpophalangeal joint of the index and middle fingers depends on the s ize of the object being held. As the size of the ob ject increases, more ulnar digits are added to butt ress and stabilize the grasp. Very small objects, s uch as marbles, may be held between the thumb and the index finger. Precision activities usually involve pulp-to-pulp grip, with the palmar surfac es of the finger and thumb facing each other. Thi s position supplies the brain with maximum sens ory input from the pulp surfaces, which are high in sensory end organs. Precision prehensile activities may be subclassifi ed as involving palmar, tip, or lateral pinch. Pal mar prehension occurs when the pulp of the thu mb is opposed to the pulps of the index and mid dle fingers. Tip pinch involves opposition of the tip of the thumb to the tips of the index and midd le fingers. The contact area is thus much greater in pulp than in tip pinch. Lateral pinch, also refer

red to as key pinch, involves the pressure of the t humb pulp against the lateral aspect of a finger, usually the index finger. Because palmar pinch is the most commonly use d pattern of prehension, it was initially suggested that surgical reconstruction and orthotic substitut ion should attempt to reproduce this pattern. Exp erience has shown, however, that the restitution of lateral pinch is a more useful and realistic goa l for the severely impaired individual.8 Tools used in precision or speed activities are de signed for a radial based grip whereas those used in slow powerful activities are designed for an ul nar based grip3 (Fig. 6-10). Other prehensile grip patterns. Obviously not all activities fall into the power grip or precision grip category. One that does not is the use of chopsticks. This r equires an intermediate grip 6 that incorporates d igital positioning midway between the typical po wer and precision postures. Another would be th e thumbless grip, in which an object such as a ci garette is actually held between the adducted fin gers. The hook grip is a form of prehensile activity in which the fingers, but not the thumb, are curled around an object. It requires a balance between t he extrinsic flexors and extensors. Prolonged po wer is often necessary, since the hook grip frequ ently is used for carrying objects such as suitcas es. It is also used for pulling actions as when ope ning a refrigerator door. MUSCLE STRENGTH Muscles may function either to stabilize a body part or to move it through space. In the upper li mb, multiple muscle groups must function in co ncert to position the forearm so other muscles ca n contract and actually perform the desired prehe nsile activity. Many hand and forearm muscles f unction primarily to pre-position the digital skel eton in a posture that will enable other muscle gr oups to contract and effect a desired motion. In g eneral, pre-positioning activities require less abs olute strength than do the forceful contractions t hat secure objects within the grasp of the hand. The force a muscle exerts is proportional to the r esting cross-sectional area of muscle fibers, with the force approximating 3.65 kilograms per squa re centimeter of muscle. A relative scale of the work capacity of extrinsic muscles has thus been calculated."' The flexor carpi ulnaris (19.6 newto n-meters) and the brachioradialis (18.7 N-m) are the strongest muscles whereas the palmaris long us, extensor pollicis longus, and abductor pollici s I~ are the weakest (1.0 N-m). The flexor carpi radialis (7.8), each of the three wrist extensors (8. 8 to 10.8), and the pronator teres (11.8 N-m) all have an intermediate potential. The flexors profundi as a gro up have a work capacity of 44.1 N-m. The interossei

combine to yield a substantial potential force (26.5 N-m) that is further amplified by combined lumbric al input (4.9 N-m). When one is contemplating either tendon transfe r or orthotic substitution of missing musculotend inous units, it is important to define the strength requirements of the missing function. By separat ing muscle activities into stabilizing, pre-positio ning, and active impacting subgroups, one is bett er able to choose an appropriate motor or orthoti c substitution. For example, although opposition of the thumb i s vital to effective precision activity, relatively li ttle motor power is necessary to bring it about. S ince it requires but minimal power, this essential function can be satisfactorily restored by the use of a variety of tendon transfers or simple orthoti c devices. Conversely, to draw the thumb toward the middle metacarpal, an essential component o f a strong power grip, requires the adductor polli cis, an extremely powerful muscle. Unfortunatel y there are no effective active orthotic substitutio ns for this muscle. At best, tendon transfer substi tution can increase lateral pinch power to only 5 0% of normal. 13 Some muscles with intermediate-level strength c an function well in limited activities but will fail in other roles. For example, although a relatively weak muscle transferred to the triceps may funct ion effectively in pre-positioning the hand in fro nt of the body or in helping to reach the hair, it will be totally insufficient to allow a tetraplegic i ndividual actively to elevate the body in perform ing an effective transfer. PATHOLOGIC HAND DEFORMITY The analysis of established hand deformities sug gests a number of underlying concepts. A basic understanding of abnormal hand postures is esse ntial to effective upper limb orthotic managemen t. Remember: each musculotendinous unit will i nfluence the posture of every joint it traverses an d the magnitude of that effect will be influenced by the position of the musculotendinous unit rela tive to the center of axis of rotation of the given j oint. The digital flexors illustrate this effect. The deep and superficial flexors of the fingers (flexor s digitorum profundi et superficiali) have a seco ndary influence on wrist motion and tend to flex the wrist as well. This tendency must be counter acted by active wrist extension if wrist position i s to be maintained in a stable posture and availab le finger flexor excursion is to be used with opti mum strength. When contracture of a soft tissue structure (e.g., musculotendinous unit) traverses two joints, a se esaw phenomenon will occur. As one joint is ext ended, increased tension will be placed on the ti ght volar musculotendinous unit and the second j oint will be passively pulled into flexion. Conver sely, when the second joint is extended. the first joint will then be flexed. It will be impossible to

extend both joints fully at the same time. Optimum volitional joint position control require s at least two musculotendinous units acting in a reciprocal direction through each plane of intend ed joint motion. This balance must be preserved at each articulation. Collateral ligaments and joi nt configuration may constrain the planes of mot ion to a single are, such as occurs at the elbow a nd the interphalangeal joints. When these constr aints are weakened, as in rheumatoid arthritis, jo ints are particularly vulnerable to deformation. When a series of joints is traversed by common musculotendinous units, a deformity of one joint may lead to reciprocal deformity of adjacent join ts. An example of this pathophysiologic interaction is the evolution of joint deformity of the rheumat oid thumb.9 In the most common deformity (Nal ebuff Type 1) synovitis begins at the metacarpop halangeal joint. The extensor apparatus becomes stretched locally while at the same time loss of j oint support (collateral integrity) allows volar su bluxation of the proximal phalanx. The loss of e xtensor integrity creates a motor imbalance that r esults in a posture of chronic metacarpophalange al flexion. This tends to tighten the extensor poll icis longus and relax the flexor pollicis longus, with the ultimate evolution of a position of inter phalangeal joint hyperextension. IMPLICATIONS FOR UPPER LIMB ORTHO TIC PRESCRIPTIONS Effective orthoses should strive to improve funct ion while requiring minimal additional energy e xpenditure and preserving remaining sensory an d motor functions. The weight of an orthosis is an important consid eration in the paralyzed or weakened limb. Most upper limb orthotic devices extend onto or aroun d the hand and thus significantly increase the we ight of the terminal portion of the limb. Because the hand rests at the end of a long lever, the weig ht of an orthosis on the hand is a significant cons ideration. A heavy orthosis may mean the differe nce between a patient's being able to lift and posi tion the hand or finding that the entire undertaking requires too m uch strength proximally to be worth the effort. It is t hus possible for an orthosis to provide substantial au gmentation of prehension but be practically useless because its weight prevents positioning of the hand i n space. The importance of preserving and facilitating re maining sensation cannot be overestimated. Sinc e the hand is often a vital area of interpersonal c ontact, the simple act of caressing or touching ta kes on tremendous significance to the paralyzed individual. An orthosis that obscures or prevents maximum exposure of sensate skin may he disca rded. Prehensile patterns must be based on remai ning sensate skin rather than on predetermined p atterns of normal functioning.

In the insensate hand it is also important that an orthosis not obscure visual cues. Since full prona tion blocks vision, the insensate hand should pro bably be positioned in a neutral position to perm it visual control. The effects of an orthosis on adjacent parts must, furthermore, be considered. All orthotic devices require either suspension or fixation proximal to the articulation that they will effect. Because the shoulder con,,~i,8ts of multiple articulations, eff ective orthotic management of shoulder weaknes s is difficult. When the function of some muscles (e.g., the latissimus dorsi) is lost, limb mobility i s easily maintained. By contrast, the loss of othe r muscles (e.g., the deltoideus) causes profound f unctional impairment. Unfortunately, scapular m ovement without glenoliumeral stability and con trol allows affected individuals only limited for ward flexion and abduction. If an orthotic device could stabilize the glenoburneral joint and maint ain scapulothoracic mobility, it would be possibl e to use the remaining muscles to compensate fo r the deltoid absence. Because such an orthosis must be proximally stabilized against the chest wall surface, however, the limb is deprived of th e action of the active motion of the scapula. Eve n if the device could pre-position the humerus in an appropriately flexed and abducted posture, it would be impossible to impart rotational stabilit y to the arm without restricting elbow motion. B ecause of the difficulties inherent in orthotic ma nagement of the flail glenohumeral joint, surgica l stabilization is often preferable in the rehabilita tion of older children and adults. CONCLUSIONS The full potential of the upper limb is best realiz ed when the arm functions in concert with the en tire body. The trunk gives the limb proximal stab ility while the shoulder maximizes its mobility. The elbow regulates the distance of the hand fro m the trunk while its orientation is controlled at t he forearm and wrist level. Optimum function of the hand depends on cerebral integration of sens ory input, both tactile and visual. An orthotic pre scription should aim at harnessing the potential o f the impaired limb without compromising remai ning sensibility or motor power. REFERENCES
1. American Society for Surgery of the Hand: The hand: examination and diagnosis, ed. 2, New York, 1983, Churc hill Livingstone, Inc. 2. Bunch, W., and Keagy, R.: Principles of orthotic treat ment. Chapter 5, Basics of upper limb orthotics, St. Louis, 1976, The C.V. Mosby Co. 3. Flatt, A.: Kinesiology of the hand. In American Acade my of Orthopaedic Surgeons: Instructional course lecture s, Vol. 18, St. Louis, 1961, The C.V. Mosby Co. 4. Hollingshead, W.: Anatomy for surgeons. Vol. 3, The back and limbs, ed. 3, New York, 1982, Harper & Row, Publishers. 5. Inman, V., Sanders, M., and Abbot, C.: Observations on the function of the shoulder joint, J. Bone Joint Surg.

26:1, 1944. 6. Kamakum, N., et al.: Patterns of static prehension in n ormal hands, Am. J. Occup. Ther. 34(7):437, 1980. 7. apandji, L: Architecture and functions of the hand. In T ubiana. R., editor: The hand, Philadelphia, 1981, W.B. So unders Co.. Vol. 1. 8. Moberg, E.: The upper limb in tetraplegia, Stuttgart, 1 978, Georg Thieme Verlag, p. 11. 9. Nalebuff, E.: Diagnosis, classification, and manageme nt of rheumatoid thumb deformities, Bull. Hosp. Joint Di s. 29:119, 1967. 10. Napier, J.R.: The prehensile movements of the human hand, J. Bone Joint Surg. 38B:902, 1956. 11. Palmer, A.K., Werner, F.W., Murphy, D., and Glisso n, R.: Normal wrist motion; a biomechanical study, J. Han d Surg. 1985. (in press.) 12. Perry, L: Normal upper extremity kinesiology, Phys. Ther. 58:265, 1978. 13. Smith, R.: Extensor carpi radialis brevis tendon transf er for thumb adduction, J. Hand Surg. 8(1)A, 1983. 14. Steindler, X: Kinesiology of the human body, Springfi eld, Ill., 1955, Charles C Thomas, Publisher. 15. Swanson, A.: The Krukenberg procedure in the juveni le amputee. J. Bone Joint Surg. 46A:1540, 1964. 16. Tichauer, EX, and Gage, H.: Ergonomic principles ba sic to hand tool design, Am. Indust. Hygiene Assoc. J. 38: 622, Nov., 1977. 17. U.S. Department of Health and Human Services: Vibr ation syndrome, NIOSH current intelligence bulletin no. 3 8, Mar. 29. 1983. 18. Von Lartz, T., and Wachsmuth: Praktische Anatorme, Berlin. 1959, Springer Verlag. Cited in Boyes, J.: Bunnel l's surgery of the hand, ed. 4, Philadelphia, 1964, J. B. Lip pincott Co.

2. To restrict motion of spinal segments after acute t rauma, after certain surgical procedures (fusion with and without internal fixation), and in the presence of any irritation exacerbated by motion (hypermobilit y, compression fractures) 3. To aid in spinal stability when the soft tissu es cannot sufficiently perform their role as stabilizer s (muscular strain, ligamentous sprain) The extent to which the multitude of spinal orthoses presently available fulfills these objectives differs v astly. ANATOMY OF THE SPINE The spine has three main functions: it stabilizes t he trunk while transferring loads from the head, trunk, and upper extremities to the pelvis; it allo ws flexibility in all three anatomic planes of the body; and it protects the integrity of the spinal c ord. The vertebral column is segmented because of it s having developed from the segmental mesoder m or somites. It is made up of 33 vertebrae-7 in t he cervical region, 12 in the thorax, and 5 in the lumbar region. The last nine segments are fusedfive in the sacrum and four in the coccyx. Howe ver., variations in this pattern are common. At birth the spine has a gentle C-shaped curve in flexion. With age, secondary curves in the sagitt al plane develop. The first to be seen is a cervica l lordosis, which occurs after independent head c ontrol is attained in the upright position. The nex t is a lumbar lordosis, which appears after uprigh t stance is attained. This leaves four curves in th e sagittal plane observable in the adult spine lord otic curves in the cervical and lumbar regions an d kyphotic curves in the thoracic and sacral regi ons. Generally the lordotic segments are more m obile than the relatively fixed kyphotic segment s. These curvatures provide substantial shock-absorbing capa bility. The basic anatomic and functional unit of the spi ne, called a spinal segment or motion segment, c onsists of two vertebrae connected by an interver tebral disc, ligaments, and muscles. Motion is pe rmitted in it by three types of articulation-the dis c, which forms a symphysis; the facet joints, whi ch are diarthrodial; and the ligaments, which for m syndesmoses. Vertebral body The vertebral body is designed to bear weight. It is composed of two types of bone, an outer shell of cortical bone and an inner core of cancellous bone. The latter makes up 60% of the bone heig ht. The laminae and pedicles form the neural arc h, which encloses the spinal canal and protects t he spinal cord. The spinous process and transver se processes are posterior structures for muscle a nd ligament attachments. They provide lever ar ms for the muscles. The facets are diarthrodial ar

Avinash Patwardhan Ray Vanderby, Jr. Gary W. Knight William J. Gogan Phyllis D. Levine

This chapter presents current knowledge and un derstanding of the important biornechanical aspe cts applicable to the function of the spine. It is di vided into two main sections. The first section h as as its objective a brief review of the anatomic aspects that are critical to understanding the bio mechanics of the human spine. The second secti on, emphasizing the normal mechanics of the spi ne, in cludes discussions on the role of the spinal musculature, the physiologic loads exerted on th e spine, and the kinematics and load-hearing cha racteristics of spinal segments. RELEVANCE TO ORTHOTIC MANAGEMEN T From a biornechanical viewpoint, a spinal orthot ic system is used for one or more of the followin g: 1. To apply corrective forces to abnormal cur vatures in the growing child (kyphosis, scoliosis)

ticulations that are critical components of. the po sterior complex of the spinal segment. In the low er cervical vertebrae (Fig. 7-1, A) the cartilage-li ned articular surface of the superior facet faces s uperiorly, posteriorly, and slightly medially. In a typical thoracic vertebra (Fig. 7-1, B) the superio r articular facet faces posteriorly, slightly superi orly, and slightly laterally. In the lumbar vertebr ae (Fig. 7-1, C) the superior facet faces posterior ly and medially. In each case there is an apposin g inferior facet that forms the facet joint. These a re synovial joints and they allow motion as well as furnish a posterior pathway during the transmi ssion of load across a spinal segment. Intervertebral disc The intervertebral disc provides flexibility to the spine in all three planes of motion along with ant erior support to the vertebral bodies. It is made u p of the nucleus pulposus and the anulus fibrosu s. The nucleus pulposus is a gelatinous substance c apable of absorbing water. It is located centrally in the cervical and thoracic discs but lies more p osteriorly in the lower lumbar region. This part o f the intervertebral articulation is a symphysis. The anulus fibrosus consists of collagen arrange d in concentric lamellae and attached above and below to the vertebral bodies. Its inner fibers pas s into and blend with the nucleus, so it is impossi ble to make a clear demarcation between the tw o. Its bands, oriented at 30 degrees to the disc pl ane (Fig. 7-2), intersect at approximately 120 de grees to each other. This orientation lends additi onal strength to the disc structure in resisting tor sional loads. Between the laminated bands is int ercellular cement. The anulus is thicker anteriorl y and laterally and thinner posteriorly, which arr angement has been suggested as playing a role i n posterior disc herniation. ligaments The ligaments contribute to the stability of the s pinal segments. There are two ligament systems: the first runs the length of the column; the secon d runs only between the vertebrae in a motion se gment. There are three ligaments in the first syst em-the anterior and posterior longitudinal and th e supraspinous (including the nuchal ligament). The second system is made up of the ligamentu m flavum. the interspinous and intertransverse li gaments, and the facet capsular ligaments (Fig. 7 -3). First system The anterior longitudinal ligament is attached to the anterior margin of each vertebral body and to the int ervertebral disc. It is wider in the lower thoracic and lumbar regions but thicker and narrower in the cervi cal region. It resists hyperextension of the spinal seg ments. The posterior longitudinal ligament lies within the s pinal canal and is attached to the posterior margin of

the vertebral body. Unlike the anterior longitudinal l igament, it is wider and thicker in the cervical and u pper thoracic regions than in the lower thoracic and lumbar region. It resists hyperflexion of the spinal s egments. The supraspinous ligament runs along the tips of the spinous processes of adjacent vertebrae. In the cervi cal region it is thickened and runs from the external occipital protuberance to the spinous process of C7. In the thoracic and lumbar regions it is thicker and b roader and blends with the surrounding fascia. It res ists hyperflexion. Second system The most important of these is the ligamentum flavum, the yellow ligament. It connects th e adjacent vertebrae, running from the poster o superior border of the lamina below to the an teroinferior border of the lamina above. It h as the highest concentration of elastin-a yello w elastic fibrous mucoprotein-which prom otes elasticity. This ligament permits separation of the laminae in flexion but slows this move ment so the anatomic limit is not reached abruptly. It is broad and thin in the cervical area, thicker in the thoracic area, and thick est in the lumbar area. In the thoracic spine it resists axial rotation. The interspinous ligament connects two adjacent spi nous processes from the base to the tip of each proc ess. It is thick in the lumbar region and only slightly developed in the cervical region. The intertransverse ligament runs between the trans verse processes. It is thin and membranous in the lu mbar region, with rounded cords in the thoracic regi on closely interrelated to the neighboring muscles, a nd scant in the cervical region. The capsular ligaments are attached to the periphera l margin of the articular facets. This arrangement all ows for sliding at the facet joints during all motions of the spine. The capsular ligaments have been sho wn to resist segmental flexion. Spinal cord An important function of the spine is to protect t he spinal cord. The spinal cord and the nerve roo ts have motor and sensory functions. Therefore a ny compromise of their integrity may lead to neu rologic symptoms. The posible mechanisms of s pinal cord trauma are compression, contusion, sh earing, and stretch. There are several factors that can act individually or in combination to cause e mbarrassment of spinal cord or nerve function-p osterior herniation of the disc, loose bony fragm ents of a fractured vertebra, hypertrophic bone f ormation, or excessive motion at the segment fro m trauma or degenerative changes in the disc or facet joints. NORMAL BIOMECHANICS The study of mechanics is generally divided into two parts-kinematics and kinetics. Kinematics is the study of motion characteristics of rigid bodie

s, with no consideration of the forces involved. Kinetics, is the study of the forces. The human s pine is part of a complex structure; therefore its mechanics cannot be realistically studied withou t taking into account the interaction with other c omponents such as the spinal musculature. This section is divided into the following subsect ions: the role of the musculature in stabilizing th e spine and amplifying the loads on it, the kinem atics of the spine, and the kinetics of the spine. Role of the spinal musculature The musculature associated with the spine and th e trunk provides motion and motion control. The stability furnished by the muscles to the spine ha s been demonstrated experimentally.24 It was sho wn that a ligamentous spine fixed at the sacrum and oriented vertically has a critical load of appr oximately 2 kg. Further loading of the specimen results in buckling. Since the head and upper tor so weigh more than 2 kg, the muscles must provi de most of the stability of the spine. The muscles of the spine and trunk can be divide d into two groups based on their anatomic locati on-prevertebral and postvertebral. The preverteb ral muscles include the four abdominals, the ilio psoas, and the precervicals. The postvertebral m uscles are divided into three subgroups: superfici al, intermediate, and deep. Direct measurement of the forces produced by s pecific muscle groups of the trunk has not yet be en accomplished. Instead, myoelectric studies ar e used. The relationship between myoelectric am plitude and muscle force is not always linear. 34 T here is a high correlation between myoelectric si gnal amplitudes and the mechanical load on the spine expressed by the disc pressure.35 The motions produced in the spine are flexion, e xtension, lateral bending, axial rotation, and com binations thereof. In a balanced vertical posture t he spine supports the upper body with minimal a ctivity from the trunk or back muscles. When the center of gravity moves anterior to the spine, the posterior muscles of the back act to balance the moment produced. Muscle activity occurs as a re sult of a posture correction to maintain the balan ced position. Flexion is initiated by the abdominal muscles, w ith the weight of the upper body tending to prod uce further flexion. Posteriorly the erector spinae muscles (iliocostalis, longissimus, costalis) contr ol this spinal motion by resisting gravitational pu ll. As flexion progresses, the myoelectric activit y of the erector spinae and superficial muscles of the back increases.4 This is due to an increase in the bending moment (caused by the overhanging weight of the upper body) that must be counterb alanced by the back muscles. At full flexion, ho wever, the myoelectric activity of the back musc les becomes minimal, for the ligaments assume a major role in constraining the motion as well as providing counterbalancing forces. In each moti

on of flexion, extension, and lateral bending the movement is initiated by a muscle set. Gravity th en increases the moment, and the control is provi ded by the antagonist muscles. Ligaments establi sh the limits of motion. Intracavitary (abdominal and thoracic) pressure is a significant factor in reducing the loads applied t o the spine. Contraction of the trunk muscles creates a nearly rigid-walled cylinder from the thoracic and abdominal cavities. These cylinders then support a p ortion of the force generated during loading of the s pine. The result is a reduction in the load on the spin e. Maximum intraabdominal pressures vary between 8.0 and 18.7 kilo-Pascals (kPa) (60 and 140 mm H g), depending on the physical stature of the individu al . With an average maximum in traabdominal pres sure of 13.3 kPa (100 mm Hg), the total force from i ntraabdominal pressure is approximately 68 kg. Sin ce this force acts over a lever arm of several centime ters, the moment generated contributes significantly to the support of the applied loads. The force on the lumbosacral disc is reduced by 30% and that on the lower thoracic disc by 50% because of the anterior s upport provided by the trunk musculature. 29 Therefo re weakening of the abdominal muscles, whether by physical inactivity, injury, or chronic elongation (e. g., due to pregnancy or obesity), causes increased sp inal loading and can lead to low back pain. Physiologic loads Loads on the spine are produced by body weigh t, muscle tension, and external forces (including gravity). Because they cannot be measured direc tly, several studies using intradiscal pressures an d free body diagrams have been done to estimate the forces generated in the spine and the spinal muscle. Measurement of lumbar intradiscal pressure5,31,33 has been used as an indirect indicator of loads i mposed on the spine. The pressure within the dis c has been found to be hydrostatic.30 Therefore, i f the disc pressure and the cross-sectional area of the disc are known, the load across a specific dis c can be calculated. Studies of the third lumbar d isc have shown that higher loads are placed on t his disc in a sitting posture, less when standing, and least in the relaxed supine position (Fig. 74). Loads calculated from the pressure values ob tained with subjects seated ranged from 100 to 1 75 kg.33 In the standing position they were betwe en 90 and 120 kg. A free body diagram of a man lifting a weight of 91 kg (200 lb) with a moment arm of 36 em (14 in) is shown in Fig. 7-5. The result is a load on t he lumbosacral discs of approximately 939 kg (2 066 lb).29 Tension in the erector spinae muscles i s 838 kg (1844 lb). This may seem high when co mpression tests by others7,9,14,37 result in failure o f the spinal segments under compressive loads ra nging from 455 kg to over 775 kg for young mal e specimens; but, remember, it does not consider the role of intraabdominal pressure (discussed u

nder "Role of the spinal musculature," p. 142). When this abdo minal force is included in the calculations, the load on the lumbar spine drops to 674 kg (and to 654 kg of tension in the erector spinae), which brings it wit hin the normal physiologic range. Even if a more co mmon weight of 23 kg (50 lb) is lifted by the man, t he estimated lumbosacral spinal loading is 235 kg (517 lb), which is still a considerable load to be bor ne by the discs. Relative isometric trunk strengths in various atte mpted motions were used with free body diagra ms to estimate forces present in the spine. 3,2" T he analysis using trunk strengths of healthy subj ects indicated that the compressive load on the s pine was maximal during attempted extension an d was approximately 225 kg. These studies also offered comparisons between healthy subjects a nd others with low back pain. In general, it was f ound that patients had about 60% of the trunk str ength of the healthy subjects. Kinematics of the spine The kinematics of the spine involves a study of t he range and pattern of motion and the coupling between components of motion of the spinal seg ments under normal and pathologic conditions. Many investigators have worked with live subje cts or autopsy specimens to determine the range and patterns of motion of the human spine. A re view of some of the early work is given by Elwa rd12; and later comprehensive surveys of this sub ject have been undertaken by Lysell25 on the cer vical spine, White43 on the thoracic spine, and R olander39 on the lumbar spine. Any data describing the range and pattern of mot ion of the spine must be interpreted with an unde rstanding of the limitations of the measurement t echniques used. These techniques generally fall i nto three categories. Early methods of in vivo m easurement involved using photographs, shadow techniques, inclinometers, goniometers, or simil ar instruments. They seldom provided satisfactor y accuracy and often led to inconsistent findings. Furthermore, detailed segmental information cou ld not be obtained. A significant improvement in precision was obtained from radiographic measu rements. Planar motion data could be obtained fr om single radiographs. Simultaneous data from t wo radiographs taken in intersecting (generally o rthogonal) planes could be used to measure three -dimensional motion of the spine. However. inac curacies in identification of bony landmarks on t he two films and the risk of overexposure were l imitations of this technique. Finally, precise mea surements of spinal motion were made on fresh cadaver speciments. The in vitro measurement te chniques involved using electromechanical goni ometers or biplanar radiography. However, beca use of the lack of active muscle participation and the absence of other structures (e.g., the rib cag e), it was then difficult to know exactly to what

extent these in vitro measurements reflected mot ion in vivo. Range of motion. Forward trunk bending involv es combined spinal flexion and hip flexion. The first 60 degrees of flexion takes place in the lum bar spine (Fig. 7-6). A forward tilting of the pelv is (hip flexion) gives another 25 degrees.15 In forward bending it is necessary to shift the buttocks posteriorly. This movement helps to keep t he center of gravity over the available base support. The motion is reversed from full flexion to a vertica l trunk position; the pelvis rotates backward and the spine extends. However, it should be noted that for ward bending can be achieved by hip flexion alone, without flexing of the spine (e.g., a ballerina or a po st-lumbar fusion patient). The hip extensors control hip flexion by providing a counterbalancing force to support the trunk against gravity. To stand upright with the pelvis tilted forward, the spine must assum e a lordotic configuration (i.e., hip flexion contractu re). Cervical spine. Cervical spine motion may be co nsidered as motion of (1) the head on the neck a nd (2) the head relative to the trunk. Nodding the head and visually indicating "no" are achieved at the upper levels. Total forward bending or looki ng at the sky involves the entire cervical spine. Both the atlantooccipital joint (Ocp-C1) and the atlantoaxial joint (C1-2) contribute approximatel y equally to the total flexion-extension motion o f the cervical spine. Axial rotation at Ocp-C1 is prevented by the anatomy of the articulation. Mo st axial rotation (up to 50%) in the cervical spine occurs at Cl-2. There is negligible translational motion at Ocp-Cl. At Cl-2, translational motions are minimal in the anteroposterior and lateral dir ections. However, during flexion-extension nor mal values of 2 to 3 min are noted for translation along the vertical direction in the midsagittal pla ne. In the lower cervical spine (C3 to C7) the C5-6 i nterspace is generally considered to have the gre atest range of motion in flexion-extension. The t otal range of the lower cervical spine in extensio n is approximately four times that in flexion. In l ateral bending and axial rotation there is a tende ncy for a smaller range in the more caudal segm ents, the C35 segments being the most mobile. T he normal values of' translation of the segments of the lower cervical spine in the anteroposterior direction (during flexion-extension) are in the ra nge of 2 to 3 mm. Thoracic spine. In flexion-extension there is a te ndency for increased motion in the more caudal segments whereas in axial rotation the tendency is for decreased motion in these segments. During walking on a level surface the most axial rotation is observed in the midthoracic segment s. 16 The cumulative (total) axial rotation gradua lly diminishes from T1 to T7. There appears to b e a transition point in the T6-8 region, below wh ich cumulative rotation increases in the opposite direction (Fig. 7-7). This transition zone shifts u

pward as a result of carrying a weight during lev el walking. From a biomechanical viewpoint, this pattern of rotation minimizes the lateral shift (in a transver se or horizontal plane) of the center of mass duri ng walking; and as a result energy consumption i s rninimized, which leads to a more efficient gai t. Any alteration in this pattern of counterrotatio n may therefore produce an "inefficient" gait. Gregersen and Lucas 16 also measured the cumu lative rotation at vertebral levels as the subjects r otated several times to the right and left under co ntrolled conditions while standing and sitting. In the standing position an average of 74 degrees of rotation occurred between the T1 and T12 level s. The measurements of axial rotation while seat ed were essentially the same. Lumbar spine. In flexion-extension there is incr eased motion at each progressively caudal level. However, in axial rotation and lateral bending th e lumbar segments do not show any dependency on the vertebral level. The average range of moti on of lumbar segments in lateral bending is some 3 to 4 ti mes greater than that in axial rotation. The lumbosa cral joint has more range in axial rotation than in lat eral bending but is most mobile in flexion-extension. Pattern of motion and coupling. The term "pat tern of motion" addresses the phenomenon of co upling motion components during, for example, flexion-extension or lateral bending. Motion cou pling in a spinal segment is governed, to a large extent, by the three-dimensional orientation of ar ticulating facet surfaces. Cervical spine. The three-dimensional orientatio n of facets provides insight into the motion coup ling behavior at different levels of the cervical s pine.10 Since the superior facets of C7 are maximally in clined with respect to the frontal plane, C6 must climb the steepest gradient during flexion, givin g rise to the most coupling between flexion angl e and vertical (caudocephalad) translation.25 At midcervical levels the coupling between flexion angle and anteroposterior translation is more pro nounced, giving rise to somewhat flatter arcs des cribed by the vertebrae. Since the facets are subs tantially inclined with respect to the sagittal and frontal planes, the coupling between lateral bend ing and axial rotation is strongest in the cervical spine compared to that in other regions of the spi ne. Here it is such that with lateral bending the s pinous processes rotate toward the convexity of t he curve. This rotation is least at C6 compared t o that at the more cephalad vertebrae. Thoracic spine. In flexion-extension the thoraci c vertebrae describe a rather flat are. The coupli ng between the lateral bending and axial rotation in upper thoracic vertebrae is similar to that in th e cervical vertebrae; that is, the spinous processe s rotate to the convexity of the lateral curve. The re is a significant change in this coupling pattern as one moves caudally. The coupling between th

ese motion components becomes less pronounce d in the midthoracic region. White43 noted sever al cases of inconsistent coupling behavior in the midthoracic region where the spinous processes rotated toward the concavity of the lateral curve. This cephalocaudal variation plus the inconsiste ncy of coupling behavior in the midthoracic regi on is thought to have some bearing on the progre ssion of thoracic scoliotic curves. Lumbar spine. In the lumbar spine the strongest motion coupling is seen between lateral bending and flexion-extension. There is some coupling b etween lateral bending and axial rotation; howev er. its pattern is opposite that observed in the cer vical and upper thoracic spine. The spinous proc esses rotate toward the concavity of the lateral c urve. There has been considerable interest in studying the instantaneous center of rotation of lumbar se gments, because the location of the center has a direct effect on the distribution of shear stresses within the intervertebral disc (a concept that ma y play a significant role in understanding the pat homechanics of disc degeneration in the lumbar spine). In thoracic segments the center of rotatio n may fall within or be anterior to the interverteb ral disc, in which case considerable axial rotatio n can occur. By contrast, in the lumbar spine the center is posterior to the disc and axial rotation i s passively restricted.16 Load-hearing characteristics of the spinal segme nts A spinal motion segment (or a functional spinal unit) is a complex mechanical system composed of adjacent vertebrae and their adjoining end pla tes. intervertebral disc, ligaments, and facet joint s. When a normal motion segment is loaded, all t hese elements contribute in varying amounts to l oad bearing. Traditionally these elements have b een grouped into two load-bearing columns, ante rior and posterior. The anterior column consisted of elements anterior to and including the posteri or longitudinal ligament. To classify acute thora columbar spinal injuries, however, Denis11 propo sed a three-column spine theory. The anterior co lumn is formed by the anterior longitudinal liga ment, anterior anulus fibrosus, and anterior part of the vertebral body. The middle column is for med by the posterior longitudinal ligament, post erior anulus fibrosus and posterior wall of the ve rtebral body. The posterior column is formed by the posterior body complex (posterior arch), sup raspinous ligament, interspinous ligament, capsu le, and ligamentum flavum. Vertebral body. A review by Rolander39 conclu ded that compressive failure occurs in the range of 0.490 to 0.735 MPa,* regardless of the level o f the vertebral body. The tests implied that break ing stress is relatively constant and the ultimate s trength of the vertebral bodies is chiefly a functi on of size. The trend is clearly one of caudally in

creas* 1 MPa = 1 million newtons per square meter. ing strength. Such a finding had earlier been echoed by Sonoda41 in his analysis of cancellous bone cubes taken from the vertebral bodies. The strength of the vertebral body generally decreases with age, especia lly after 40 years. This is attributable to a reduction i n osseous tissues.8,17,18 The load transmitted through the vertebral body takes two pathways, one through the cortical she ll and the other through the trabecular core. Roc koff38 et al. showed that the cancellous core prov ides 35% to 55% of the compression strength of a lumbar vertebral body depending on age. The t rabeculae are aligned primarily in an axial direct ion and thus have a columnlike load-bearing beh avior, which accounts for the considerable loss i n strength of the vertebral body associated with a small decrease in osseous tissue. There are three types of load-deformation curve, all with a similar elastic portion.22 However, afte r the initial elastic portion, each curve can follow any of three paths-which define an ultimate failu re load that may be. substantially greater than, ap proximately equal to, or somewhat less than the yield point load. Although such data are extreme ly scattered, certain trends become evident. The more desirable behavior (ultimate failure strengt h greater than yield strength) occurs most freque ntly in males under 40 years, and the least desira ble behavior (ultimate failure below yield) occur s usually in females over 40. The latter situation represents a point of structural instability at yield and can translate clinically to a higher predisposi tion toward bone fracture in middleaged and old er women. Trabecular bone not only shares load with the co rtical shell but also plays a significant role in abs orption of impact loads. This "shock absorber" f unction is greatly enhanced by the presence of b one marrow.19 The vertebral body (and specifically its cancello us bone) has been shown to possess remarkable r estorative capabilities after extreme loading. Alt hough Lindahl22 reported that compressive failur e occurs at 9.5% strain, Kazarian and Graves 21 h ave shown that a vertebral body compressed bey ond yield and then unloaded is capable of regaini ng much of its original height. In one extreme ca se they demonstrated that within 72 hours the ve rtebral body regained 75% of its original height after mechanical compression to 50%. Electron microscopy has demonstrated that this phenome non is due to the fact that the trabeculae fold wit h the initial compression and then gradually unfo ld upon unloading.13 End plate. While testing spinal motion segment s, many researchers27,40 have observed fracture of the end plate as the initial mode of compressive f ailure. Motion segment failure occurs as a result of either end plate failure or compression failure

of the vertebrae, depending on the rate of loadin g.37 Impacting loads produced a higher incidence of end plate fracture than did loadings that were eff ectively static. Central fractures occurred more o ften in the presence of nondegenerated discs, and peripheral fractures in the presence of degenerat ed discs. Neural arch. The specific contribution of the po sterior element is hard to separate from total seg mental behavior. Measured strengths indicate tha t high levels of load are required to produce failu re in the posterior elements. Facet joints. Studies have indicated that the face ts carry approximately 16% of the total axial loa d. This value is increased in hyperextension and decreased in spinal flexion. The lower lumbar le vels carry higher loads than the upper. Ligaments. Ligaments are uniaxial structures th at possess substantial strength in tension but buc kle readily in compression. The force-deflection characteristic of a typical ligament is nonlinear (i. e., the stiffness increases with load). In addition, ligaments are viscoelastic insofar as their stiffnes s increases with increasing rate of loading and di splays hysteresis between the loading and unload ing curves. Studies32 show the ligamentum flavum to be pret ensioned (approximately 15% strain) in the neutr al position. It was hypothesized that this pretensi oning-18 N in young subjects (20 years) to 5 N i n older subjects (70 years)-adds stability to the s pine as well as prevents the ligamentum from be coming slack in spinal extension. Because of pre tensioning, the ligamentum still has a positive 5% strain when the motion segment is fully exte nded. When it is fully flexed, the ligamentum ha s 35% strain and can be stretched even farther in trauma. This provides a substantial rise in segme ntal stiffness to protect the spinal cord during ext reme flexion loadings. The anterior and posterior longitudinal ligament s, like the discs, have been observed to degenerat e with age. Maximum deformation, residual defo rmation, and energy loss due to histeresis were f ound to decrease with age.42 The anterior longitu dinal ligament was approximately twice as stron g as the posterior, but this phenomenon reflected a change in size rather than any significant difference in material properties. These ligaments were also fo und to have some degree of pretensioning although no quantitative data on this were given. It is likely that the intertransverse ligaments, bec ause of their positioning, play a substantial role i n spinal stiffness for lateral bending and perhaps torsion. The capsular ligaments have been shown to be i mportant in the stability of the cervical spine.36,44 They also provide substantial resistance to flexio n in a lumbar segment, more than do the ligamen tum flavum and the supraspinous and intraspino us ligaments.1 However, the lumbar capsular liga

ments do not play a significant role in axial com pression 23 or torsion of the spinal segment.2 Intervertebral disc. The intervertebral disc cont ributes more to the stability of a motion segment than does any other single element. It has been s hown to bear a significant load in compression, s hear, bending, and torsion. It is the only element of the spine whose morphology allows substanti al load-bearing capabilities for any and all of the se combinations. The mechanics of an intervertebral disc are stron gly affected by the presence of fluid within the a nulus. A typical load-deformation curve for a dis c in compression (Fig. 7-8) is nonlinear, with a s lope that increases throughout the range of loadi ng. Thus the disc is more compliant at lower loa ds, to provide spinal flexibility, and much stiffer at higher loads, to provide strength and stability. This stiffening phenomenon is observed as far as the point at which failure begins. The disc, like the ligaments, is viscoelastic; it th erefore exhibits the mechanical characteristics of relaxation, creep, and hysteresis as well as a load rate dependency in its stiffness. These characteri stics allow the spinal column to absorb shocks a nd are important in spinal stability. Fig. 7-9, A, s hows the typical relaxation behavior of an interv ertebral disc in which the load required to maint ain a constant deformation decreases with time. B shows the typical creep behavior when the def ormation continues to increase with maintenance of a constant load. This creep phenomenon is the likely cause of the shortening in one's height obs erved between morning and evening. It is signifi cantly affected by disc degeneration: the greater the degeneration, the less the disc exhibits visco elasticity.20 The implication of this finding is that a degenerated disc is less able to attenuate shock s. High load rates can produce tears in the anulus fi brosus, but lower rates of loading have never bee n shown to produce any irreversible damage to a n intact intervertebral disc (in one load cycle).27 The viscoelastic character of the material allows slowly applied loads to distribute themselves in s uch an efficient load-bearing configuration that t he end plate (e.g., Schmorl's nodes) will always fail first. The only time that lower load rates will produce disc failure is in degenerative fatigue. Tensile properties of the anulus fibrosus are imp ortant in the behavior of a spinal motion segmen t. When the segment is subjected to a compressi ve load, the outward pressure of the nucleus pulp osus causes the anulus to bulge and develop tens ile stresses in the direction of the fibers. This is a lso true of a degenerated disc, but only for the ou termost fibers. Other modes of physiologic loading similarly produce annular tension in the disc: 1. In lateral bending the annular fibers on the convex side of the curve are in tension while those o n the concave side are subjected to a complex of str

esses consisting of axial compression (due to shorte ning) and tension (due to bulging). 2. In flexion or extension a similar type of bending behavior takes place, with the tensile side being post erior in flexion and anterior in extension. 3. In torsion the concentric layers of fibers in the an ulus are alternately in tension and in compression, v arying with their directional orientation. 4. In loading, tensile stresses are produced at a 45-d egree angle from the direction of loading. Mechanical properties of the disc have been meas ured experimentally at different locations in the spin e: 1. The disc is less stiff in tension than in com pression,26 due in part to the absence of the annular f luid pressure that builds up in compression and also to the orientation of the annular fibers. The anterior and posterior portions of the dis c are the strongest.9 Thus it can be seen that t he disc is capable of bearing greater loads in flexion-extension than in lateral bending. 3. An intact disc possesses a high stiffness in shear. This implies that it provides a great deal of re sistance to small shearing motions between adjacent vertebrae. Ribs and rib articulations. In the thoracic regio n the rib cage plays an important biomechanical role in stiffening and strengthening the spine. Th e costovertebral joints provide additional ligame ntous support to the motion segment, and the rib cage increases the skeletal moment of inertia of t he spine to resist bending movements and torque s. An intact rib cage doubles the stiffness of the l igamentous spine in extension. In other motions, however, the improvement in stiffness due to the rib cage is only 25% to 50%.6 ACKNOWLEDGMENT The authors would like to express their gratitude to Drs. Wilton H. Bunch and Robert D. Keagy, f or reviewing this chapter and providing valuable suggestions, and to Ms. Maureen Havey, for preparation of the figures. REFERENCES
1. Adams, M.A., and Hutton, W.C.: The effect of posture on the role of the apophysial joints in resisting int ervertebral compressive forces, J. Bone Joint Surg. 62B.3 58, 1980. 2. Adams, M.A., and Hutton, W.C.: The relevance of torsion to the mechanical derangement of the lumbar spine, Spine 6:241, 1981. 3. Addison, R., and Schultz, A.B.: Trunk strengths in patients seeking hospitalization for chronic low back di sorders, Spine 5:539, 1980. 4. Andensson, G.B.J., Ortengren, R., and Herberts, P.: Quantitative electromyographic studies of back muscle activity related to posture loading, Orthop. Clin. North A m. 8:85, 1977. 5. Andersson, G.133---Ortengren, R., and Nachem son, A.: Intradiscal pressure, intraabdominal pressure, and myoelectric back muscle activity related to posture and lo ading, Clin. Orthop. Rel. Res. 129.156, 1977. 6. Andriacchi, T.P., Schultz, A.B., Belytschko, T.

B., and Galante, J.O.: A model for studies of mechanical i nteractions between the human spine and rib cage, J. Bio mech. 7:497, 1974. 7. Bartelink, D.L.: The role of abdominal pressure in relieving the pressure on the lumbar intervertebral disc s, J. Bone Joint Surg. 39B:718, 1957. 8. Bell, G.H., Dunbar, 0., Beck, J.S., and Gibb, A.: Variation and strength of vertebra with age and the relatio n to osteoporosis, Calcif. Tissue Res. 1:75, 1967. 9. Brown, T., Hansom, R., and Yorra, A.: Some m echanical tests on the lumbosacral spine, with particular r eference to the intervertebral discs, J. Bone Joint Surg. 39 A:1125, 1957. 10. Chmell, S., Patwardhan, A., Vanderby, R., and Light, T.: Threedimensional orientation of articular facets of the lower cervical spine. In Transactions of the 29th An nual Meeting of the Orthopedic Research Society, Anahei m, Calif., March, 1983, p. 210. 11. Denis, F.: The three column spine and its signifi cance in the classification of acute thoracolumbar spinal i njuries, Spine 8:817, 1983. 12. Elward, L: Motion of the vertebral col umn, A.J.R. 42:91, 1939. 13. Eurell, J.A.C., and Kazarian, L.E.: Th e scanning electron micros copy of compressed vertebral bodies, Spine 7:123, 1982. 14. Evans, G., and Lissner, M.S.: Biomec hanical studies of the lumbar spine and pelvis, J. Bone Joi nt Surg. 41A:278, 1959. 15. Farfan, II.F.: Muscular mechanisms of the lumb ar spine in the position of power and efficiency, Orthop. C lin. North Am. 61:135. 1975. 16. Gregersen, G.G., and Lueas, D.B.: An in vivo st udy of axial rotation of the human thoracolumbar spine, J. Bone Joint Surg. 49A:247, 1967. 17. Hansson, T.H., and Roos, B.: The influence of a ge, height, and weight on the bone mineral content of lum bar vertebrae, Spine 5:545, 1980. 18. Hansson, T.H., Roos, B.O., and Nachemson, A. L.: The bone mineral content and ultimate compressive str ength of lumbar vertebrae, Spine 5:46, 1980. 19. Hayes, W.C., and Carter, D.R.: The effect of ma rrow energy absorption of trabecular bone. Presented at th e 22nd Annual Meeting of the Orthopedic Research Socie ty, New Orleans, 1976. 20. Kazarian, L.E.: Creep characteristics of the human spinal column, Orthop. Clin. North Am. 6:3, 1975. 21. Kazarian, L.E., and Graves, G.A.: Co mpression strength characteristics of the human vertebral column, Spine 2:1, 1977. 22. Lindahl, 0.: Mechanical properties of dried defatted spongy bone, Acta Orthop. Scand. 47:11, 1 976. 23. Lorenz, M., Patwardhan, A., and Vanderby, R., Jr.: Load-bearing characteristics of lumbar facets in norm al and surgically altered spinal segments, Spine 8:122, 19 83. 24. Lucas, D., and Bresler, B.: Stability of ligament ous spine, Biomechanics Laboratory Report no. 40, Unive rsity of California, San Francisco, 1961. 25. Lysell, E.: Motion in the cervical spin e, Acta Orthop. Scand., suppl. 123, 1969. 26. Markolf, K.L.: Deformation of the thuracolumb ar intervertebral joint in response to external loads: a bio mechanical study using autopsy material, J. Bone Joint Su rg. 54A:511, 1972. 27. Markolf, K.L., and Morris, J.M.: The structural components ofthe intervertebral disc, J. Bone Jo int Surg. 56A:675, 1974.

28. MeNeill, T., Warwick, D.. Andensson, G., and Schultz, A.: Trunk strengths in attempted flexion, extensi on, and lateral bending in healthy subjects and patients wi th low-back disorders, Spine 5:529, 1980. 29. Morris, J.M., Lucas, D.B., and Bressl er, B.: Role of the trunk in the stability of the spine, J. Bo ne Joint Surg. 43A:327, 1961. 30. Nachemson, A.: Lumbar intradiscal pr essure: experimental studies on post mortern material, Act a Orthop. Scan., suppl. 43, 1960. 31. Nachemson, A.: The load on lumbar d iscs in different positions of the body, Clin. Orthop. Rel. Res. 45:107, 1966. 32. Nachemson, A., and Evans, J.: Some mechanica l properties of the third human interlaminar ligament (liga menturn flavum), J. Biomech. 1:211, 1968. 33. Nachemson, A., and Morris, J.M.: In vivo measurements of intradiscal pressure, J. Bone Joint S urg. 46A:1077, 1964. 34. Ortengren, R., and Andensson, G.B.J.: Electrom yographic studies of trunk muscles, with special reference to the functional anatomy of the lumbar spine, Spine 2:44, 1977. 35. Ortengren, R., Andersson, G.B.J., and Nachems on, A.L.: Studies of relationships between lumbar disc pre ssure, myoelectric back muscle activity, and intra-abdorni nal (intragastric) pressure, Spine 6:98, 1981. 36. Panjabi, M.M., White, A.A., and Johnson, R. M.: Cervical spine mechanics as a function of transection of components, J. Biomech. 8:327, 1975. 37. Perry, 0.: Fracture of the vertebral end -plate in the lumbar spine, Acta Orthop. Scand., suppl. 25, 1957. 38. Rockoff, S.D., Sweet, E., and Bleustem, J.:. The relative contribution of trabecular and cortical bone to the strength of human lumbar vertebrae, Calcif. Tissue Res. 3: 163, 1969. 39. Rolander, S. D.: Motion of the lumbar spine, wi th special reference to the stabilizing effect of posterior fu sion, Acta Orthop. Scand., suppl. 90, 1966. 40. Rolander, S. D., and Blair, W. D.: Def ormation and fracture of the umbar vertebral end-plate, Or thop. Clin. North Am. 6:75, 1975. 41. Sonoda, T.: Studies on the strength for compres sion, tension and torsion of the human vertebral column. (Japanese with English summary.) J. Kyoto Pref. Med. Un iv. 71:659, 1962. 42. Tkaezuk, H.: Tensile properties of hu man lumbar longitudinal ligaments, Acta Orthop. Scand., suppl. 115, 1968. 43. White, A.A.: Analysis of the mechani cs of the thoracic spine in man, Acta Orthop. Scand. 42:4 82, 1969. 44. White, A.A., Johnson, R.M., Panjabi, M.M., an d Southwick, W.O.: Biomechanical analysis of clinical sta bililty in the cervical spine, Clin. Orthop. Rel. Res. 109:8 5, 1975.


Robert L. Waters Brenda Rae Lunsford It is commonly assumed that level walking requi res minimal effort since no net mechanical work is performed (upward work against gravity is eq ualed by passive downward travel). However, m etabolic energy is expended whenever muscles c ontract. During walking there is continuous mus cle activity: in the swing phase the flexors advan ce the limb and lift the foot to clear the floor; in t he stance phase the extensors restrain the influen ce of momentum and gravity. It has been demon strated13,14 that during normal walking, movemen t of the limbs is so patterned that the least mecha nical and physiologic energy is expended. There are five common types of lower limb disa bility that may require orthotic support: joint inst ability, paralysis, spasticity, joint deformity, and pain. The data summarized in this chapter touch on physiologic limitations of persons with a gait dysfunction that requires orthotic management, t he physiologic penalties of restricted joint motio n, and the added energy cost of upper extremity aids (crutches and canes) as well as the energetic s of wheelchair propulsion. This information can provide clinically useful predictors of a patient's capacity for functional mobility and an explanati on of why some patients discontinue walking. PRINCIPLES OF EXERCISE PHYSIOLOGY The rationale for energy cost measurements rests on the basic principles of exercise physiology.2 Aerobic and anaerobic metabolism The use of oxygen consumption as a measure of energy expenditure relies on the fact that during sustained exercise most of metabolism is aerobi c. After several minutes of working at a constant submaximum load, the rate of oxygen consumpti on is sufficient to meet the energy demands of th e tissues. The heart and respiratory rates also rea ch approximately constant levels, and the subject is said to be in a steady state. Measurement of th e rate of oxygen consumption at this time accura tely reflects the energy cost of the activity. The principal fuels for aerobic metabolism are c arbohydrates and fats. In aerobic oxidation these substrates are oxidized through a series of enzy matic reactions, leading to the production of AT P for muscular contraction. A second oxidative r eaction is also available that does not require ox ygen. In anaerobic metabolism (glycolytic pathw ay) glucose is converted to pyruvate and then to lactic acid. During prolonged exercise there is an interplay b etween aerobic and anaerobic mechanisms. Duri ng mild or moderate exercise (less than 50% of t he

maximal aerobic capacity for untrained individuals) the oxygen supply to the tissue and the capacity of a erobic energy-producing mechanisms are usually su fficient to satisfy energy requirements. During more strenuous exercise both anaerobic and aerobic oxida tion processes occur. The amount of energy that can be produced by a naerobic means is limited. Nineteen times more energy is produced by the aerobic oxidation of c arbohydrates than by anaerobic oxidation. The b ody's limited tolerance of the acidosis resulting f rom the accumulation of lactic acid also limits a naerobic oxidation. From a practical standpoint t he anaerobic pathways provide muscles with an i mmediate supply of energy for sudden bursts of strenuous activity. If exercise is performed at a constant moderate r ate below the anaerobic threshold, an individual can sustain it for many hours with no easily defi ned point of exhaustion. When exercise is perfor med at increasing levels above the anaerobic thr eshold, however, the endurance time progressive ly shortens and fatigue ensues earlier. Maximum aerobic capacity max) is the single be st indicator of physical fitness. Generally an indi vidual is able to reach maximal oxygen uptake w ithin 2 or 3 minutes of beginning severe exercis e. Any disorder of the respiratory, cardiovascula r, muscular, or metabolic systems that restricts th e supply of oxygen to the cells decreases the m ax.2 A physical conditioning program can increa se the aerobic capacity by several processes: imp roving cardiac output, increasing the capacity of the cells to extract oxygen from the blood, increa sing the level of hemoglobin, and increasing the muscular mass (hypertrophy) . The max also depends on the type of exercise. D uring lower limb exercise it is greater than durin g exercise with the upper limbs. At the same rate of oxygen uptake, the heart rate for upper limb e xercise is higher than for lower extremity exercis e.2 Astrand's nomogram1,2 makes possible the predic tion of a person's max for lower limb exercise, b ased on the heart rate and oxygen consumption d uring submaximum exercise multiplied by an ag e correction factor. Methods of oxygen measurement Investigators have studied the energy costs of wa lking gait by performing energy cost analyses w hile the subject walked on a treadmill or at a reg ulated velocity, or both. These conditions freque ntly impose difficulties for disabled patients, par ticularly when crutch assistance is required. The modified Douglas bag method, which we have u sed, 16 allows subjects to select their own natura l speed of walking on a stationary level surface a nd permits testing during their customary walkin g conditions. A lightweight air collection system is harnessed to the subject's shoulders, and expir ed air is collected (Fig. 8-1). Heart rate, respirato

ry rate, and cadence are all monitored and the re adings transmitted via a portable radio telemetry system. Gas collection immediately follows a wa rm-up period after the subjects have achieved a s teady state as determined by leveling of the heart rate. The standard analysis measurement, performed on all subjects, is the rate of oxygen uptake. Dat a are divided by the body weight of each subject to permit comparisons and therefore are express ed as milliliters per kilogram per minute (ml/kg/ min). All reported data are in STPD units (stand ard temperature pressure dry). Data from our ear lier reports in BTPS units (body temperature pre ssure saturated) have converted to STPD units. A second method of expressing oxygen consum ption is the energy cost, which equals the volum e of oxygen consumed in milliliters per kilogram body weight per meter walked (ml/kg/m). Oxyge n cost is calculated by dividing the rate of oxyge n consumption by the walking speed. ENERGETICS OF WALKING Normal The energy cost of normal walking provides the standards against which the added penalties imp osed by abnormal gait can be compared. Since a preliminary report on 40 subjects, we ha ve tested a total of 225 normal subjects between the ages of 6 and 80 years.17,18 The subjects were divided into four groups-children (6 to 12 years), adolescents (13 to 19 years), adults (20 to 59 yea rs), and seniors (60 to 80 years). We noted that e nergy expenditure was highly dependent on age but there were no differences due to sex. The mean rate of energy expenditure for adults a nd seniors was approximately the same, 11.9 and 11.8 ml/kg/min (Table 8-1). In the younger age groups it progressively increased, averaging 12.9 ml/kg/min for teenagers and 15.3 for children. The data on heart rate paralleled the findings on rate of oxygen consumption. The mean for child ren. 114 beats per minute (bpm), was significantl y higher than for adolescents and adults (Table 8 -1). The oxygen cost of walking a unit distance (met er) was higher in children and adolescents than i n adults 0.22 and 0.18 ml/kg/m versus 0.15 ml/k g/m. For seniors it was not significantly greater t han for adults. (The higher values in the younger age groups are attributable to a combination of i ncreased rate of energy expenditure and slower g ait velocity.). The max depends on age. Fig. 8-2 shows the pro gressive decline with advancing age-40 ml/kg/m in for subjects in the third decade, 40 in the fourt h, 34 in the fifth, 28 in the sixth, and 24 in the se venth. Consequently, older individuals require a larger percentage of their available energy suppl y to walk-49% for ages 60 to 69 years versus 3 0% for ages 20 to 29. These results have important clinical implication

s. Anaerobic threshold is approximately 50% ma x for healthy untrained subjects. Below this level the normal individual can sustain exercise for pr olonged periods without exhaustion. accounting for the fact that normal walking is perceived as r equiring minimal effort. The typical older adult has a much smaller energy production capability and lacks aerobic reserves to accomodate either i ncreased energy requirements caused by gait disabilit y or decreased exercise capacity caused by gerontol ogic diseases. On the same basis, the decreased max imum exercise capacity accounts for the common cl inical experience of older patients' with gait disorder s complaining increasingly of fatigue and progressiv e restriction of mobility with advancing years and e ven stopping walking. By contrast, younger individ uals often willingly tolerate much greater physiologi c stress, and even endure discomfort. before limiting or ceasing an activity as important as walking. Walking with lost joint motion Walking requires smooth rhythmic motions of th e lower extremities. The normal biomechanical d emands are minimized by body alignment and m omentum. The ability to move in a smooth unint errupted manner is acquired by muscles that are adequately strong and joints that move freely. A ny condition which alters the normal posture, an d/or joint motion, will increase the energy dema nd. To understand better the problem of joint motion loss, consider the following two experiments: In the first, knee flexion contracture was simulated by artificially restricting knee extension in norm al subjects; in the second, the knee and/or ankle j oints were completely immobilized. Joint restriction. Orthopaedic conditions requiri ng orthotic management are commonly associate d with joint contractures. The importance of preventing and reducing knee flexion deformity was illustrated by a study 12 i n which the energy cost penalties associated wit h walking on a flexed knee were evaluated. A sp ecially designed hinged knee orthosis restricted r ight knee extension to 15, 30, and 45 degrees in 20 nor mal subjects but allowed full flexion. The device consisted of proximal thigh and distal tibi al bands connected by lateral and medial hinged side bars. Popliteal restraining straps opposed th e extension. Progressively greater than normal rates of energ y expenditure and decreases in walking velocity were required when the amount of simulated kne e flexion contracture was increased. Restricting knee extension to 15 degrees caused a 7% rise in the rate of O2 consumption and an 11% decrease in walking efficiency. Restricting to 30 degrees l ed to a 15% rise in O2 uptake and a 19% decrease in efficiency. Limiting to 45 degrees resulted in a 21% increase an

d a 32% loss (Table 8-2). Gait velocity declined wit h increasing amounts of joint restriction. As a consequence of the increased rate of oxyge n consumption and reduced gait velocity with pr ogressive amounts of knee restriction, appreciabl e changes in the energy cost between levels of re striction occurred, progressing to a 46% increase at the 45-degree position (Fig. 8-3). During normal standing the floor reaction force between the center of pressure of the foot a~d th e center of gravity of the body passes close to th e axis of rotation of the hip and knee joints and s lightly ahead of the axis of the ankle joint in the sagittal plane. Consequently, relatively little mus cle activity is required to maintain the standing p osture. During normal walking, to minimize the muscular effort required for antigravity support, the floor reaction force remains relatively close t o the axis of the hip, knee, and ankle joints durin g the period of singlelimb support. Perry et al. 11 e xamined the biomechanical requirements of flex ed-knee stance and demonstrated the need for in creased quadriceps, tibiofemoral, and patellofem oral forces. The most significant increases occur red at angles of knee flexion beyond 15 degrees, a finding that parallels the significant changes in energy expenditure observed in this study. Limited knee extension requires compensatory a lterations of normal motion and muscle activity at other joints and functionally shortens the leg, l imiting the length of an individual's step. The pat ient typically walks with increased hip flexion in an effort to realign the trunk over the foot. Incre ased ankle extension with floor contact only on t he forefoot during stance may be present to com pensate for functional leg shortening. To functio nally shorten the contralateral limb, the patient may also purposefully increase contralateral hip, knee, and ankle flexion in stance. In comparison to normal standing and walking, these gait devia tions significantly increase the muscular effort re quired to stabilize the hip, knee, and ankle joints. The clinical impact of knee flexion deformity is twofold. First, the increase in energy expenditur e can be devastating. A high mean rate of oxyge n uptake was observed in a group of children wit h spastic diplegic cerebral palsy who typically us ed a "crouch" gait with excessive hip and knee fl exion when walking.16 (The high rate of oxygen consumption was also due to the fact that many of these children required upper extremity aids.) Older patients may not he able to meet this energ y demand and may stop walking. Second, the m uscle and joint forces experienced when walking with a contracture serve to make the original pro blem worse. Therefore preventive efforts in man aging patient with trauma, arthritis, or other joint diseases should be, aggressive. Once contracture has occurred. intensive specialized therapeutic ef forts are needed. Contractures of 15 degrees or l ess that have no potential for increasing create a minimum penalty, but the existence of (or the po tential for reaching) 30 degrees of deformity is a

major clinical concern. These findings support the following orthotic gu ideline: To permit normal limb alignment, lower extremity contractures should be corrected befor e definitive orthotic fitting, particularly when fre ely moving (orthotic) joints are prescribed. joint immobilization. Total loss of joint motion results from surgical arthrodesis or an orthosis d esigned to block motion of the knee or ankle. The effects of complete immobilization were ev aluated in a study's in which the dominant leg of 20 normal male volunteers was placed in a long l eg plaster cast, with the knee and ankle immobili zed in the neutral position, and a cast boot was p laced over the foot. Initial testing was performed in the long leg cast. Then the long leg cast was modified to a short leg cast or cylinder cast and r etesting was performed. By interfering with normal knee motion, substitu tion was necessary at other joints (e.g., hip hikin g, circumduction, vaulting). To accomplish these extra motions with physiologic comfort, the subj ects slowed their self-selected gait velocity. The rates of oxygen consumption remained at normal levels, ranging from 13.0 to 12.7 ml/kg/min (Ta ble 8-3). Likewise, the average heart rates for th e three types of cast were no greater than for nor mal walking. Walking speed depended directly on the extent o f immobilization. The average velocity in a short leg cast was 70 m/min, in a cylinder cast 64 m/m in, and in a long leg cast with both knee and ankl e immobilized 56 m/min. Joint immobilization resulted in significantly gre ater energy costs and, depending on the extent of immobilization, reduced gait efficiency. The ave rage net oxygen cost was 0.24 ml/kg/m for the lo ng leg cast, 0.20 for the cylinder cast, and 0. 19 f or the short leg cast compared to 0.15 for normal walking (Fig. 84). The overall effect of walking with joint restriction was to reduce efficiency to 63%, 75%, and 79% of normal (according to the type of cast). These findings support the following clinical rul e: Joint motion should be permitted in an orthosi s when sufficient muscle control and strength are present to move the joint normally through the a vailable range. To do otherwise is to unnecessari ly condemn the patient to a reduced walking spe ed and efficiency. Crutch walking The patient requiring lower extremity orthotic su pport frequently may depend on crutch assistanc e for walking. In a study15 to determine the effects of crutches o n energy expenditure, we tested 20 normal subje cts walking with a swing-through gait and weigh tbearing on one leg. Unlimited non-weightbearin g, crutch-assisted, swing-through gait proved to be a high-energy consumption experience. Energ y demands were elevated, and the velocity and e fficienty of walking decreased. Compared to val ues obtained in the same subjects during normal

walking, the rate of oxygen consumption increas ed 70%, heart rate increased 48%, velocity decre ased 23%, oxygen cost increased 233%, and gait efficiency dropped 57% (Table 8-4). We also have recorded high rates of energy expe nditure in complete spinal cord-injured paraplegi cs who walked using bilateral KAFOs, crutches, and a swing-through gait.5 On the bases. of rate of oxygen uptake and cardi ac response, the physical exertion experienced d uring swing-through crutch walking (which requ ires the arms to lift the total body weight with ea ch step) can be compared to that during other typ es of exercise. The rate of energy expenditure re quired for swing-through crutch ambulation is a bove the anaerobic threshold of the typical adult s and is equivalent to a variety of recreational, sp orts, and industrial activities classified as "heavy work" (e.g., shoveling coal).3 These findings account for the common clinical experience that, even after extensive orthotic ma nagement to stabilize the legs, the patient with se vere disability who depends on a swing-through crutchassisted gait will be restricted to short inte rvals. Most patients, and particularly older indivi duals whose exercise capacity is reduced by age, may be unable to meet this energy demand. ENERGETICS OF WHEELCHAIR PROPULSI ON Manual wheelchair propulsion is the preferred m eans of locomotion for many individuals with lo wer extremity disability. In a study is of the energy costs of wheeling, we tested three groups normal young adults with no prior wheelchair experience, neurologically intac t patients who had used a wheelchair for at least 1 month and were considered deconditioned, and healthy paraplegics with complete T10-12 lesion s who had used a wheelchair for at least 3 month s. The testing was done on two types of surface, concrete and standard indoor-outdoor carpeting with a 1/4-inch banded foam backing, and perfor mances were analyzed with both hard rubber tire s and pneumatic tires. All three groups traveled significantly more slo wly on the carpeted surface than on the concrete (Table 8-5)-the normal subjects 23% more, the d econditioned subjects 30%, and the paraplegic s ubjects 21% with hard rubber tires and 20% with pneumatic tires. All three groups, likewise, demonstrated a highe r mean oxygen uptake per minute on the car peted surface than on the concrete; but the increases were not statistically significant, except for the para plegic group using pneumatic tires. All three group s, however, did experience increased energy cost pe r unit of distance traveled on the carpeted surface (T able 8-5)-the normal group 37% increased, the deco nditioned group 56%, and the paraplegic group 41% with hard rubber tires and 36% with pneumatic tires. Whereas the two patient groups manifested elev

ated mean heart rates when propeling their whee lchairs on both surfaces (Table 8-5), the mean he art rate of the normal subjects was not greatly el evated. Heart rates also did not vary much betwe en surfaces, except for the paraplegic group usin g pneumatic tires (concrete, 127 bpm; carpet, 13 6; p <0.01). When the performances of the paraplegic group using pneumatic tires were compared to their per formances using hard rubber tires, no statisticall y significant difference was noted in any of the v ariables. Carpeting of the type commonly used in hospital s imposed a burden on the subjects in the form o f a significantly higher oxygen cost, between 3 6% and 56% depending on the group and the typ e of tire. Because the subjects were allowed to c hoose their own velocity, they responded to the i ncreased resistance of the carpet by slowing dow n. This enabled them to complete the trials on ca rpet with only a slight increase in oxygen uptake per minute. The slower speed, however, meant t hat the total energy expenditure to go a given dis tance was greater on the carpet. If the subjects h ad been forced to travel at the same velocity on both surfaces, the oxygen uptake per minute wo uld probably have been significantly higher on t he carpet. For the 15 paraplegic subjects pneumatic tires of fered no advantage over hard rubber tires on eith er surface. The heart rates observed in this study for the pati ent groups were considerably higher than values reported for wheeling in normal subjects. Even t he paraplegics, some of whom had been using w heelchairs for years, averaged heart rates over 13 0 bpm. Although the average rates of oxygen uptake we re approximately the same, the significantly high er heart rates in the deconditioned group of subje cts compared to those in the normal subjects wer e consistent with their reduced exercise capacity. The elevated heart rates in the group of parapleg ics were related to the fact that upper extremity a erobic capacity is reduced in this population and probably also to the fact that venous return and v asomotor tone both are reduced in the lower extr emities. The paraplegic patients were experienced wheel chair perambulators. Their average velocity, rate of energy expenditure, and oxygen cost on the h ard concrete surface were strikingly similar to th e values for normal walking. Wheelchair propuls ion is a very efficient method of transportation o n such a surface for the patient who cannot walk. ORTHOTIC DESIGN Although weight can be an important factor to s ome patients, the rigidity of the orthotic system a nd/or the availability of joint motion can be equa lly important. Plastic, because if its potential to b e lighter than metal, is sometimes considered pre

ferable. For the patient with weak hip flexors, ef forts to minimize weight imposed by the orthosis and shoe are warranted since any extra weight at the end of the limb will make it more difficult to lift the foot and advance the leg. In an effort to quantify energy differences, Corc oran et al.7 studied a group of hemiparetic patien ts walking with and without conventional metal and plastic orthoses. No differences in energy ex penditure were found between the metal and the lighter plastic orthoses. Data recently collected on three different levels of spinal cord injured patients at Rancho Los A migos Hospital support the Corcoran et al.7 findi ngs. No significant differences were obtained in any of the following parameters: velocity, heart r ate. oxygen consumption, and energy cost. This means that the lighter weight of plastic orthoses does not influence energy expenditure and perfo rmance. Lelineis et al.9 found that improving orthotic sta bility reduces energy costs. Since energy cost is t he end result of muscular effort and normal mus cular effort is higher during the stance phase tha n the swing phase, these findings are logical. Du ring swing phase an effort is needed to advance t he limb, which comprises 15% of total body mas s. however, during stance phase the total body m ass requires support8 It follows, then, that in any orthotic design, stability should not be sacrificed merely to achieve lighter weight. An example will illustrate the importance of ene rgy expenditure considerations in orthotic desig n. When limb stability is being considered, two f actors are important-the rigidity of materials use d and the avoidance of undesirable torque impos ed by the orthosis itself. Studies performed by th e Orthotic Department at Rancho Los Amigos H ospital10 have shown that a reinforced polypropy lene AFO restrains dorsiflexion at terminal stanc e significantly better than does a conventional po lypropylene AFO. Further research6 indicated th at the type of plastic, its thickness, the trim lines, and any reinforcement are all important factors i n achieving rigidity. With these parameters in op timum combination, a plastic orthosis can offer a greater degree of rigidity than can a metal one. When an ankle is locked in a rigid orthosis, desir ed stability is gained during midstance and termi nal stance while an undesired thrust or torque is i mposed, forcing the knee into flexion at the mo ment of contact and loading that the heel has wit h the floor. This knee flexion torque is generated because the rigidly immobilized leg rotates forw ard at the point of heel contact. During normal g ait this torque is avoided when ankle plantar flex ion minimizes the effect of the heel level. With t he ankle locked, an increased demand is placed on the quadriceps, increasing energy demand. We have adopted two courses of action to obtain ankle stability during terminal stance while not c reating instability at heel strike. If the patient has fair plus (F+) or better ankle dorsiflexion strengt

h and intact proprioception, we fit a metal AFO with a long-tongued stirrup and double adjustabl e ankle joint. A set screw in the anterior channel provides an adjustable stop that prevents excessi ve dorsiflexion. The posterior channel is left ope n to allow free plantar flexion. A spring may be i nserted in the posterior channel to assist dorsifle xion. The advantage gained is that restriction of motion during terminal stance is maintained whi le the normal plantar flexion motion during loadi ng is preserved, thus avoiding the undesired kne e flexion torque. If the patient has less than fair d orsiflexors or absent proprioception at the ankle, then the ankle is locked and either metal or plasti c is used. To avoid the excessive knee flexion to rque when the ankle is locked, the heel of the sh oe is undercut. This undercut decreases the heel l ever and thus the knee flexion torque. ACKNOWLEDGMENT
The authors wish to express their thanks to Jacquelin Perry, M.D., Professor, Department of Orthopedic Sur gery, University of Southern California, and Director of the Pathokinesiology Laboratory, Rancho Los Ami gos Hospital, Downey, California; to Helen Hislop, P h.D, Professor and Chairperson, Department of Physic al Therapy, University of Southern California; and to t he Physical Therapy Students of the University of Sou thern California who assisted in patient testing.

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